Abstract: Objective:To investigate the diagnosis and treatment of congenital mesenteric hiatal hernia in aduls.
Methods:The retrospective crosssectional study was conducted. The clinical data of 11 adult patients with congenital mesenteric hiatal hernia who were admitted to the First Affiliated Hospital of Henan University from January 1999 to January 2016 were collected. All patients underwent abdominal Xray and ultrasound examinations. Patients diagnosed as with intestinal obstruction or suspected intraabdominal hernias underwent abdominal CT examination, and then were finally confirmed during surgery. Patients diagnosed as with mesenteric hiatal hernia received necrotic tissues resection and tissue repair (small intestine resection and anastomosis) if there was necrosis of hernia contents, and closing mesenteric hiatus. Patients without small intestine necrosis received closure of mesenteric hiatus after retraction of the hernia contents. Observation indicators: (1) clinical manifestations, (2) imaging findings, (3) treatment, (4) pathological examination, (5) followup situations. Followup using outpatient examination and telephone interview was performed to detect the postoperative complications up to March 2017.
Results:(1) Clinical manifestations: all 11 patients were acute onset, with incentives of satiation, postprandial exercise and diarrhea. The time from onset to admission was 2.0-30.0 hours, with an average time of 9.8 hours. The main symptoms included abdominal pain, nausea and vomiting, exhaust reduction and other intestinal obstruction performances. Eleven patients received physical examination, and 10 showed abdominal bulge, including 9 with intestinal type. Eleven patients had abdominal tenderness, and 9 combined with rebound tenderness. Abdominal percussion of 11 patients showed hyperresonant without shifting dullness, and active, muted and fading bowel sounds were detected in 1, 3 and 7 patients, respectively. (2) Imaging examination: of 11 patients receiving abdominal Xray examination, 2 had intestinal loop and 4 had the intestinal obstruction performances such as typical gasliquid plane. Abdominal ultrasound examination of 11 patients showed no specific findings due to abdominal intestinal gas, and 10 with peritoneal effusion. Of 11 patients, 1 didn′t receive abdominal CT scan due to preoperatively misdiagnose with acute appendicitis and 10 underwent abdominal CT scan. Nine patients were diagnosed with intestinal torsion by abdominal CT scan and then underwent enhanced CT scan, and 8 with small mesenteric vascular torsion and swirling sign were diagnosed with small intestine torsion and partial necrosis of small intestine. (3) Treatment: 1 patient preoperatively misdiagnosed with acute appendicitis was converted to exploratory laparotomy, and 10 patients underwent exploratory laparotomy due to complete intestinal obstruction or progressive increase in symptoms. Intraoperative exploration showed that intestinal mesenteric hiatus and colon mesenteric hiatus were respectively in 8 and 3 patients, and hiatuses were round or oval, with a diameter of 2.0-8.0 cm and an average of 4.4 cm. Hernia contents were small intestine. The partial small intestine in 10 patients were resected and then mesenteric hiatus was closed due to necrosis of the small intestine, with removal length of 110-250 cm and an average of 176 cm, and length of remaining small intestine was 80-230 cm, with an average of 159 cm. The hernia into small intestine in 1 patient without complete necrosis was retracted to abdominal cavity after symptomatic treatment, and closing mesenteric hiatus. Eleven patients were cured and out of hospital after operation, without nosocomial complications. (4) Pathological examination: small intestine ischemic necrosis was detected in 10 patients after partial small intestine resection. (5) Followup situations: all patients were followed up for 12-24 months, without malnutrition, short bowel syndrome and other complications.
Conclusions:Without history of abdominal trauma or surgery, with incentives of the satiation, postprandial exercise and diarrhea, abnormal retroperitoneal small intestine shadow and small intestinal torsion diagnosed by CT scan and absent intestine sign by enhanced CT scan can be helpful to diagnose congenital mesenteric hiatal hernia in adults and small intestinal necrosis. Surgery is the only effective method in the treatment of congenital mesenteric hiatal hernia in adults.