What is it:

This disease have an unique feature. Usually in hernia cases, the intestinal loops that enter into the hernial sac become gangrenous. But in this case (Maydl’s Hernia), the intestinal loops that enter into the hernial sac remain normal, but the loops that remains inside the abdominal cavity become gangrenous and toxic. This is why high level of suspicion is necessary to clinch the diagnosis.

Case report:

One gentleman of 47 years old was admitted with septic shock & multi-organ failure under Dr S P Mahato in ICU set up. He was literally gasping and on the verge of dying. He was put on Ventilator for respiratory support and blood pressure (Nor Adrenaline) support immediately.

Clinically, he had peritonitis with large irreducible left inguinal hernia, but without any signs of hernial obstruction. Straight X-ray abdomen failed to show any free gas under diaphragm. USG of abdomen & scrotum also gave very little information. Moreover, CECT abdomen could not be done due to on going sepsis induced kidney injury. So, the decision making for surgery was based upon only over the clinical judgment of perforative peritonitis alone. Patient had been on blood thinner Ecospirin for recent cardiac stenting, leading to increase chance of bleeding perioperatively. He would die if we do not operate him earliest. But, any surgical procedure in this situation itself having high mortality rate. After describing all the facts, relatives gave consent for the emergency surgery.

On surgical exploration a very rare type of hernia was found in left inguinal canal. It was a Maydl’s hernia or ‘Hernia in W’. The intervening intra-abdominal loop was strangulated, gangrenous and perforated leading to pus filled abdominal cavity. Resection of the gangrenous intestine with stoma formation was done and abdomen was irrigated with 5 L Normal saline to clean the pus. After that hernial defect was repaired. The procedure itself and the anesthesia both were challenging. It took nearly three and half hour to complete the whole procedure.

The post operative battle in the ICU was prolonged with unpredictable ups and downs. The gentleman battled for his life with ventilator support for nearly 2 weeks. He had been suffering from one of the worst kind of poly-microbial sepsis with sensitivity to very few top-most antibiotics. After completing 20 days in ICU and 10 days in the ward, the gentleman was discharged.

Inference:

Hernia-in-W is a very rare type of hernia. but, the hernia complicates early and deteriorates very fast. Being unfamiliar with this entity, it can be tough to diagnose. It should be suspected in patients with large incarcerated hernia, with evidence of strangulation or peritonitis or with viable loops of intestine in the hernia sac. This blog post is aimed to raise awareness for it and saved life.