Overview
Definition:
Internal hernia at Brolin's point refers to a protrusion of abdominal contents through a defect in the abdominal wall at the site of a previous surgical incision, specifically at or near the linea alba, often inferior to the umbilicus where the rectus sheaths converge
Surgical closure aims to repair this defect and prevent recurrence.
Epidemiology:
Internal hernias at Brolin's point are uncommon and typically arise in the context of incisional hernias following abdominal surgery
Risk factors include previous midline laparotomies, wound infections, obesity, and factors compromising wound healing
Prevalence data is limited, but they are a recognized complication of abdominal surgery.
Clinical Significance:
This type of internal hernia can lead to bowel obstruction, strangulation, and perforation, posing significant morbidity and mortality
Prompt diagnosis and definitive surgical closure are crucial for patient outcomes and preventing life-threatening complications
It is a critical topic for surgical residents preparing for board examinations.
Clinical Presentation
Symptoms:
Intermittent or persistent abdominal pain, often localized to the site of the previous scar
Nausea and vomiting, particularly with signs of bowel obstruction
Abdominal distension
Palpable or visible bulge at the hernia site, which may be reducible or irreducible
Signs of bowel obstruction such as obstipation or obstipation with diarrhea
Signs of strangulation include severe, constant pain, fever, tachycardia, and peritoneal signs.
Signs:
A visible or palpable defect in the abdominal wall, usually at the site of a surgical scar
Tenderness on palpation over the hernia sac
Signs of bowel obstruction on physical examination, such as hyperactive bowel sounds or absent bowel sounds in later stages
Peritoneal signs (rebound tenderness, guarding) may indicate strangulation.
Diagnostic Criteria:
Diagnosis is primarily clinical, confirmed by imaging
Criteria include a history of abdominal surgery, presence of an abdominal wall defect at or near Brolin's point, and evidence of abdominal contents protruding through this defect, often with associated symptoms of obstruction or strangulation
Definitive diagnosis is often made intraoperatively.
Diagnostic Approach
History Taking:
Detailed history of previous abdominal surgeries, including type and location of incisions
Previous complications such as wound infections or dehiscence
Onset, duration, and character of abdominal pain
Presence and nature of gastrointestinal symptoms (nausea, vomiting, bowel habits)
Red flags include acute onset of severe pain, fever, and signs of systemic compromise.
Physical Examination:
Careful inspection of the anterior abdominal wall for scars and bulges
Palpation of the scar area to identify defects, tenderness, and reducibility of any bulge
Assess for signs of bowel obstruction (distension, bowel sounds)
Perform a digital rectal examination if obstruction is suspected
Assess for peritoneal signs, which suggest complications like strangulation.
Investigations:
Abdominal X-ray: May show signs of bowel obstruction such as dilated loops of bowel, air-fluid levels, and paucity of gas distally
Computed Tomography (CT) scan: The gold standard for diagnosing internal hernias, especially with oral and intravenous contrast
It can delineate the hernia sac, its contents, and any signs of bowel compromise (e.g., wall thickening, ischemia, pneumatosis intestinalis)
Ultrasound: May be useful for detecting superficial hernias but is less sensitive for internal defects.
Differential Diagnosis:
Other types of incisional hernias (e.g., umbilical, epigastric)
Spigelian hernia
Rectus sheath hematoma
Abdominal wall abscess
Desmoid tumor
Adhesions causing bowel obstruction
Diverticulitis
Inflammatory bowel disease flare
Ovarian torsion (in females).
Management
Initial Management:
For suspected obstruction or strangulation, initial management includes nil per os (NPO), intravenous fluids, nasogastric tube decompression, and broad-spectrum antibiotics
Pain management is essential
Urgent surgical consultation is paramount.
Surgical Management:
Indications for surgery are symptomatic internal hernias, confirmed hernias with risk of strangulation, or established bowel obstruction/strangulation
Surgical approach: Laparoscopic or open surgery
Hernia repair involves reduction of the herniated contents and closure of the fascial defect
For Brolin's point hernias, a mesh repair (e.g., underlay or inlay technique) is often preferred to reduce recurrence rates, especially in larger defects
Techniques include primary fascial closure or prosthetic mesh reinforcement
If strangulated bowel is present, resection and anastomosis may be required.
Postoperative Care:
Postoperative care includes pain management, monitoring for bowel function, gradual return to oral intake, and wound care
Ambulation is encouraged to prevent deep vein thrombosis and pulmonary complications
Monitoring for signs of infection or recurrence is important.
Supportive Care:
Nutritional support may be required in cases of prolonged ileus or bowel resection
Close monitoring of vital signs, fluid balance, and urine output is essential
Postoperative physiotherapy may be beneficial for respiratory and mobility status.
Complications
Early Complications:
Bowel obstruction, bowel strangulation and ischemia, perforation, hemorrhage, wound infection, seroma, hematoma, mesh infection, mesh dehiscence, deep vein thrombosis, pulmonary embolism, prolonged ileus.
Late Complications:
Hernia recurrence, chronic pain, mesh-related complications (e.g., erosion, migration, chronic inflammation), incisional hernia at other sites, adhesions causing future bowel obstruction.
Prevention Strategies:
Meticulous surgical technique during primary abdominal surgery to minimize tissue trauma and ensure secure fascial closure
Appropriate suture material and technique
Management of risk factors such as obesity and diabetes
Prompt recognition and treatment of wound infections
Use of prosthetic mesh for repair of large or recurrent defects to reduce recurrence rates.
Prognosis
Factors Affecting Prognosis:
The presence and severity of complications such as bowel strangulation or perforation significantly impact prognosis
The patient's overall health status, presence of comorbidities, and the success of surgical repair are also crucial factors
Early diagnosis and treatment generally lead to better outcomes.
Outcomes:
With timely diagnosis and successful surgical repair, the prognosis for internal hernias at Brolin's point is generally good, with resolution of symptoms and prevention of recurrence
However, complications like strangulated bowel can lead to significant morbidity and mortality.
Follow Up:
Regular follow-up appointments are recommended to monitor for signs of hernia recurrence, especially in the early postoperative period
Patients should be advised to report any new or worsening symptoms
Long-term follow-up may be necessary depending on the complexity of the repair and the presence of risk factors.
Key Points
Exam Focus:
High-yield for DNB/NEET SS: Recognize Brolin's point as a common site for incisional internal hernias post-midline laparotomy
Understand the risk of strangulation and obstruction
CT scan is the investigation of choice
Mesh repair is often indicated for definitive closure to prevent recurrence.
Clinical Pearls:
Always consider internal hernia in patients with previous abdominal surgery presenting with signs of bowel obstruction, especially if pain is localized near a scar
Don't overlook Brolin's point as a potential hernia site
Intraoperative assessment for occult defects is vital
Prophylactic mesh use should be considered in high-risk patients.
Common Mistakes:
Delaying surgical intervention in suspected strangulation
Misdiagnosing the hernia as a simple incisional hernia without considering internal contents
Inadequate fascial closure or inappropriate mesh placement leading to recurrence
Neglecting thorough preoperative assessment of comorbidities that affect wound healing.