Table of Contents  

Kamal, Alzoabi, Muhammad, Badri, and Al Mazrouei: Internal supravesical hernia

Introduction

The supravesical fossa is a triangular area of the anterior abdominal wall bounded laterally and superiorly by the median and medial umbilical ligaments. The inferior extent of the fossa is bounded by the peritoneal reflection passing from the anterior abdominal wall to the dome of the bladder.1 A hernia in this fossa can form as a result of a defect in the integrity of the transversus abdominis muscle and fascia transversalis. The hernial sac protrudes through the abdominal wall as an external supravesical hernia. In rare instances, the sac passes downwards into the spaces around the bladder to form an internal supravesical hernia. These internal supravesical hernias most commonly occupy the space of Retzius.

In the medical literature, 58 cases of internal supravesical hernia have been reported. The first case of internal supravesical hernia, according to Keynes, was reported by Sir Astley Cooper in 1804, but a thorough discussion of this rare type of hernia began only after 1940.2

Internal supravesical hernia is difficult to diagnose and can present as intestinal obstruction or as undiagnosed abdominal pain.3

We report one case of surgically proven internal supravesical hernia with an irreducible left inguinal hernia. Abdominal computerized tomography (CT) showed the relation of the incarcerated intestine anterior to, and compressing, the bladder. We propose that preoperative diagnosis of supravesical hernia by abdominal CT is possible, as suggested by this case.

Case report

A 72-year-old man presented with a history of colicky abdominal pain for 2 days and vomiting associated with constipation for 4 days. He had had no previous abdominal surgery. On examination, he was dehydrated with a heart rate of 126 bpm, blood pressure of 116/79 mmHg and a temperature of 37°C. His abdomen was distended and diffusely tender with guarding mainly over the lower abdomen. There was an irreducible left inguinal hernia (Figure 1) that disappeared after the patient received an analgesic and a period of bed rest; there was also a reducible right inguinal hernia. Blood tests showed leucocytosis. Plain film radiography showed distended small-bowel loops with air–fluid levels consistent with a small-bowel obstruction.

FIGURE 1

Abdominal CT (coronal view) showing left inguinal hernia.

HMJ-719-fig1.jpg

Computerized tomography showed a high-grade, distal, small bowel obstruction with a transitional zone in the lower abdomen. Below the transitional zone there was a sac-like mass of clustered bowel loops within a hernia sac, which indicated an internal hernia (Figure 2). The hernia sac was situated in the prevesical space, compressing the anterior bladder wall, and passed downwards to cause an obstructed left inguinal hernia (Figure 3).

FIGURE 2

Abdominal CT scan (coronal view) showing an internal supravesical hernia pushing the bladder to the right.

HMJ-719-fig2.jpg
FIGURE 3

Abdominal CT scan (axial view) showing internal herniation in the lower abdomen.

HMJ-719-fig3.jpg

Diagnostic laparoscopy showed incarcerated internal herniation of the small bowel in the area of the prevesical space. As a result of densely adherent bowel loops, the operative procedure was changed to laparotomy through lower midline incision. The internal supravesical hernia was identified (Figure 4), the bowel returned to the abdomen and the hernia defect closed with a non-absorbable suture. The left inguinal hernia was repaired with a non-absorbable mesh. The post-operative stay was uneventful and the patient was discharged on the fourth day after the operation.

FIGURE 4

(a) Intraoperative view of herniated bowel loops with (b) hernial orifice indicated with forceps.

HMJ-719-fig4a.jpgHMJ-719-fig4b.jpg

Discussion

Infrequently, a hernia in this location occupies the prevesical space of Retzius, and this is referred to as an internal supravesical hernia. The internal hernia, in turn, can be of several types. It can be prevesical, paravesical, lateral or intravesical. When the bladder apex is weakened by a defective closure of the urachus, the diverticulum may herniate directly into the bladder, forming the intravesical type of internal supravesical hernia.1,4

These cases can present in a variety of ways: as intestinal obstruction, as an irreducible inguinal hernia accompanied by an internal supravesical hernia or as vague abdominal symptoms. Clinical diagnosis of this hernia is almost never suspected before operation; however, familiarity with the anatomy of the supravesical fossa may allow preoperative diagnosis by CT in a few instances.5

Abdominal magnetic resonance imaging and diagnostic laparoscopy have also been suggested as diagnostic tools for this type of hernia.6 Some authors have described the role of cystoscopy and herniography in diagnosing the condition.1,7 Some of the cases have been diagnosed only at exploratory laparotomy undertaken for bowel obstruction.810

In this case, a pre-existing irreducible inguinal hernia diverted attention from the internal hernia. Abdominal CT suggested herniation in the supravesical location.

The majority of cases recorded so far have resulted in exploratory laparotomy. In cases of clinically evident intestinal obstruction, treatment of the condition involves the release of the intestinal obstruction and closure of the hernial defect. Most authors advise that trimming the edges of the ring, with closure of the defect using continuous or interrupted stitches of any non-absorbable sutures, is sufficient. They have not advised to attempt to excise the hernial sac.10

Summary

Supravesical hernia is a rare type of internal hernia situated in the supravesical fossa. Prior to our case, 58 cases had been reported in the literature worldwide. It can cause small-bowel obstruction and is particularly difficult to diagnose.

This case presented as an irreducible inguinal hernia with some features of bowel obstruction and, therefore, an internal hernia was not suspected as the cause of intestinal obstruction. Preoperative diagnosis of this internal hernia was very difficult. However, CT raised suspicion of the condition because of the presence of a herniated loop near the bladder and abdominal wall distortion; these findings were confirmed during exploratory laparotomy. Treatment consisted of reduction of the herniated bowel from the supravesical hernial orifice and closure of the defect with non-absorbable sutures. The accompanying inguinal hernia was repaired with mesh.

This case illustrates the difficulty of diagnosing this rare type of internal hernia. It also demonstrates that the presence of an internal hernia with an obvious inguinal hernia can make diagnosis even more challenging.

Conclusion

It is suggested that, when a supravesical defect is found during routine surgical exploration of the pelvis, it should be sutured to avoid incarceration of the bowel. The reported case reiterates the difficulty of diagnosing this rare hernia and calls attention to the entity as an unusual cause of small-bowel obstruction.

References

1. 

Sawyers JL, Stephenson SE. Internal supravesical hernia; report of the first successful operative repair of the intravesical type. Surgery 1957; 42:368–74.

2. 

Keynes WM. Chapter 41: Supravesical hernia. In: Nyhus LM, Harkins HN (eds.) Hernia. Philadelphia: JB Lippincott; 1964.

3. 

Skandalakis PN, Skandalakis LJ, Gray SW, et al. Supravesical hernia. In: Nyhus LM, Condon RE (eds.) Hernia, 4th edn. Philadelphia: JB Lippincott; 1995. pp. 400–11.

4. 

Barnes DR, Dreyer BJ. Internal supravesical hernia: report of a case presenting with bladder symptoms. Br J Surg 1953; 40:508–9. https://doi.org/10.1002/bjs.18004016321

5. 

Sasaya T, Yamaguchi A, Isogai M, Harada T, Kaneoka Y, Suzuki M. Supravesical hernia: CT diagnosis. Abdom Imaging 2001; 26:89–91. https://doi.org/10.1007/s002610000134

6. 

Chou CK, Liu GC, Chen LT, Jaw TS. The use of MRI in bowel obstruction. Abdom Imaging 1993; 18:131–5. https://doi.org/10.1007/BF00198049

7. 

Gullmo A. Herniography. The diagnosis of hernia in the groin and incompetence of the pouch of Douglas and pelvic floor. Acta Radiol Suppl 1980; 361:1–76.

8. 

Tretbar LL, Gustafson GE. Internal supravesical hernia. A rare hernia causing small bowel obstruction. Am J Surg 1968; 116:907–8. https://doi.org/10.1016/0002-9610(68)90463-7

9. 

Köksoy FN, Soybir GR, Bulut TM, Yalçin O, Aker Y, Köse H. Internal supravesical hernia: report of a case. Am Surg 1995; 61:1023–4.

10. 

Sozen I, Nobel J. Inguinal mass due to an external supravesical hernia and acute abdomen due to an internal supravesical hernia: a case report and review of the literature. Hernia 2004; 8:389–92. https://doi.org/10.1007/s10029-004-0222-9




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