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| Year : 1987 | Volume
: 33
| Issue : 3 | Page : 137-9 |
Unusual Maydl's hernia (a case report).
Narang RR, Pathania OP, Punjabi PP, Tomar SS
How to cite this article:
Narang R R, Pathania O P, Punjabi P P, Tomar S S. Unusual Maydl's hernia (a case report). J Postgrad Med 1987;33:137 |
Maydl's hernia is a very rare hernia and sometimes presents as a perplexing situation which appears to be more common in strangulated sliding hernias. The hernia contains two loops of bowel arranged like a 'W'. The central loop of the 'W' lies free in the abdomen and is strangulated where as the two loops present in the sac are not. There is a paucity of references to this condition in the literature though it is mentioned in few standard textbooks of surgery.[5],[9] Rarity of Maydl's hernia together with certain uncommon features present in our patient prompted this case report.
K. R., a 50 year old male, gave a 24 hours' history of colicky abdominal pain and pain in the left inguinal region with vomiting and progressive abdominal distension. He had a lump in the left inguinal region for 20 years but this had not previously been tender and hitherto had been reducible. In past, he had refused surgery .on many occasions.
On examination; the patient was very ill and markedly dehydrated and toxic. The pulse was 110/min. and blood pressure 80/60 mm Hg. There was generalised abdominal tenderness, guarding and a massive, tense, tender and irreducible left inguinal hernia was present. Nasogastric aspirate yielded faeculent material.
At operation, the hernial sac contained 250 ml of foul smelling brownish fluid and operative findings are shown in [Fig. 1]. At this stage the patient collapsed and was resuscitated successfully. Caecum, appendix and about 1.5 meters of small bowel were gangrenous. [Fig. 2] This was treated by resection and end to end anastomis and herniorrhapy was performed. The patient remained in a critical condition for a week and than gradually recovered. The patient was able to leave the hospital on 25th post-operative day and the wound healed satisfactorily.
Karel Maydl, (as mentioned by Monro[5]) a Bohemian surgeon (1853-1903) in 1895 first described the condition in which segments of the bowel proximal and distal to an infolded loop may become irreducible within the hernial sac without loss-of viability, while the infolded loop may become strangulated. Maydl's hernia also known as hernia-in-W or double loop hernia is regarded as a rare complication of strangulated inguinal hernia and an incidence of 0.6%, 1.9% and 1.92% has been reported by various authors.[1],[4],[8]
Review of the available literature shows that Paul[7] reported a male patient with Maydl's hernia in 1944 and in another study of 157 cases of strangulated hernias, Cole[2],[3] could collect only 3 cases of Maydl's hernia requiring resection of small intestine only. Philips[8] in 1967 reported 15 cases of right sided hernia with afferent loop strangulation and in all these cases caecum was freely mobile in the hernial sac. Bayley[1] in 1970 discussed presentation and management of 5 patients with Maydl's hernia. Of these patients, only 3 had caecum as one of loops present in the sac. Moss et al[6] in 1976 reported a rather unusual case of Maydl's hernia in which all the loops were large bowel and patient underwent right hemicolectomy as the loops of caecum, ascending colon and hepatic flexure were gangrenous.
Maydl's hernias are more common in males and occur more frequently on right side, features also noted in large series of strangulated inguinal hernia.[4],[8] Small intestine or omentum or both may be involved in the strangulation process but for the large bowel to become strangulated in an inguinal hernia is of the utmost rarity.[9] Our case, though a male patient, had large hernia on the left side of 20 years' duration and besides containing small bowel had mobile caecum and appendix (gangrenous). The intra-abdominal gangrenous small bowel loop was 1.5 meter long. This necessitated massive small bowel resection and excision of the caecum and appendix before continuity of gut was restored by ileocolic anastomosis.
Pre-operative diagnosis of Maydl's hernia should be suspected when examination reveals evidence of peritonitis, fluid depletion or a tender mass is palpable in the lower abdomen in a patient with painful and irreducible but not necessarily tense inguinal scrotal swelling.1 Treatment is by emergency operation but when dehydration and collapse are present (as in our case), intravenous fluid therapy and nasogastric decompression for 1 to 3 hours are invaluable. According to Sir Astley Cooper,[9] (as mentioned by Rains and Ritchie[9]), "The danger is in the delay, not in the operation."
| 1. | Bayley, A. C.: The clinical and operative diagnosis of Maydl's hernia; A report of 5 cases. Brit. 3. Surg., 57: 687-690, 1970  |
| 2. | Cole, O. J.: Strangulated hernia in Ibadan: A survey of 165 patients. Trans. Roy, Soc. Trap. Med. & Hyg., 58: 441-447, 1964. |
| 3. | Cole, G. J.: A review of 436 cases of intestinal obstruction in Ibadan. Gut, 6: 151-162, 1965. |
| 4. | Frankau, C.: Strangulated hernia: A review of 1487 cases. Brit. J. Surg., 19:176-191, 1931. |
| 5. | Monro, K. A.: Strangulated external abdominal hernia. In, "Abdominal Operations". Editor: R. Maingot, 6th edition, Vol. 2. Appleton-Century-Crofts, New York, 1974, p. 1571. |
| 6. | Moss, C. M., Levine, R., Messenger, N. and Dardick, I.: Sliding colonic Maydl's hernia: Report of a case. Dis. Col. & Rect., 19: 636-638, 1976. |
| 7. | Paul, M.: Maydl's hernia. Brit. J. Surg., 32: 110-101, 1944. |
| 8. | Philips, P. J.: Afferent limb internal strangulation in obstructed hernit. Brit. J. Surg., 54: 96-99, 1967. |
| 9. | Rains, A. J. H. and Ritchie, H. D.: In, Bailey and Love's Short Practice of Surgery". 18th edition. The English Language Book Society and H. K. Lewis and Co. Ltd., London, 1981, pp. 1143-1144. |
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