Presentation
Right sided abdominal pain. Dilated loops on abdominal x-ray.
Patient Data
There is a large right Spigelian hernia containing multiple loops of small bowel. A transition point is seen in the ileum as it enters the hernia. Dilated loops are seen within the hernia with further transition points within the small bowel as it exits and re-enters the hernia (Maydl's hernia). There is moderate surrounding soft tissue stranding in keeping with incarceration. The large bowel is collapsed.
Bilateral small (right: 5cm, left: 6cm) scarred kidneys and a right iliac fossa transplant kidney.
The remaining intra-abdominal viscera are unremarkable within the limitations of a non-contrast CT. No free intraperitoneal gas.
Conclusion
Large right Spigelian hernia containing multiple loops of small bowel (Maydl hernia) with an associated closed-loop small bowel obstruction.
Case Discussion
A Maydl's hernia is a rare type of hernia where more than one loop of bowel enters the hernial sac, with an intervening intra-abdominal loop which is at risk of a closed-loop obstruction.
Findings confirmed at laparotomy.
The hernia was present before the renal transplant, although much smaller, hence is classified as a Spigelian hernia rather than an incisonal hernia. The incision is remote to the hernia also.
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