Herniation of small bowel through the peritoneal defect of the Pouch of Douglas is extremely rare type of internal hernia, and this type of internal hernia has been described as an entity of perineal hernia. Here, we describe a case of a 26-year-old female without history of abdominal surgery presenting with incarcerated small bowel hernia through a peritoneal defect of the Pouch of Douglas. She visited an emergency department presenting with abdominal pain and distension. Without improvement symptom by conservative management, an operation was performed. During the operation, the distal ileum had been herniated through a peritoneal defect of the Pouch of Douglas, and there were no specific findings on gynecological examination. Reduction of the herniated bowel and primary repair of the peritoneal defect were performed. The case represents a very rare type of internal hernia and provides published cases of hernia through a peritoneal defect of the Pouch of Douglas.
Intestinal obstruction caused by internal hernia is rare, with an incidence of between 0.2% and 0.9% [
A 26-year-old woman was admitted to the emergency department of Ilsan Paik Hospital with abdominal pain and distension lasting for 3 days. She had no history of abdominal surgery. Abdominal examination revealed mild distension and hyperactive bowel sounds. Signs of peritoneal irritation were not apparent and there were no remarkable laboratory data. Plain abdominal X-ray showed a dilated small bowel loop without free air. An emergency computed tomography (CT) revealed diffuse dilatation in proximal to mid ileal loop with abrupt luminal narrowing at distal ileum level without definite evidence of bowel ischemia (Figure
Axial CT image shows distended proximal bowel loop and collapsed distal loop (white arrow) at a transition zone (black arrow) between the uterus (asterisk) and the rectum (star).
Without improvement of symptoms and physical findings during conservative management, the patient underwent an exploratory laparotomy on 3rd hospital stay. During the operation, approximately 5 cm length of the distal ileum (45 cm from the ileocecal valve) had been herniated into a defect of the Pouch of Douglas, and there were no specific findings of pelvic examination (Figure
Operative findings. The distal ileum is herniated into the defect of the Pouch of Douglas (arrow).
After reduction of the herniated bowel, peritoneal defect between the uterus and the rectum is shown (arrow).
In patients without history of abdominal surgery, causes of bowel obstruction such as colorectal cancer, inguinal hernia, intussusception, volvulus, and inflammatory bowel disease might be diagnosed based on physical examination and imaging studies preoperatively. However, the preoperative diagnosis of internal hernia may be difficult although preoperative diagnosis through CT has been reported [
Congenitally created peritoneal defect and foramen may lead to internal hernias [
The Pouch of Douglas is an anterior peritoneal reflection between the uterus and the rectum which is so-called rectouterine pouch. Multiparity, old age, and history of pelvic surgery may lead to weakening or defect of the pelvic floor resulting in herniation of bowel though the Pouch of Douglas [
Clinical features of internal hernia through a defect of the Pouch of Douglas in English literature.
Author (year) | Age | Symptom | History of abdominal surgery | Diagnosis made by/at | Defect of the Pouch of Douglas | Management |
---|---|---|---|---|---|---|
Fiirgaard and Agertoft (1988) [ |
17 | Abdominal pain, nausea, vomiting | No | Surgery | Congenital | Reduction and primary repair of a peritoneal defect |
Hoeffel et al. (1992) [ |
76 | Abdominal pain, vomiting | NA | Surgery | NA | Small bowel resection and anastomosis |
Inoue et al. (2002) [ |
80 | Abdominal distension, vomiting | Hysterectomy | Surgery | Acquired | Reduction and primary repair of a peritoneal defect |
Bunni et al. (2012) [ |
77 | Pain in right groin | No | Surgery | Congenital | Laparoscopic mesh herniorrhaphy |
Present case |
26 | Abdominal pain, distension | No | Surgery | Congenital | Reduction and primary repair of a peritoneal defect |
NA = no available information.
The definitive diagnosis usually has been made during the surgery, although CT findings of hernia through a peritoneal defect of the Pouch of Douglas have been reported, in which a cluster of collapsed small bowel loops in the peritoneal defect between the rectum and the uterine cervix may be detected [
The surgical treatments of perineal hernia consist of reduction of hernia sac, ligation, excision, and approximation of the uterosacral ligament, or obliteration of hernia sac using continuous sutures through the posterior wall of the cervix and the anterior wall of the rectum [
The preoperative diagnosis of internal hernia may be elusive because of the rarity of the disease entity, especially unusual type of internal hernia. Delayed diagnosis and treatment could result in morbidity and mortality. Thus, even though hernia through a peritoneal defect of the Pouch of Douglas is an extremely rare type of internal hernia and its preoperative diagnosis is difficult, a high degree of suspicion based on CT findings and history of abdominal surgery may be necessary for prompt management.
The author declares that there are no conflicts of interest regarding the publication of this paper.