Omental herniaton through umbilicus following lower segment caesarean section in a post caesarean pregnancy

Chandana Das and Snehamay Chaudhuri

Introduction

The incidence of caesarean section is rising¹ and there is evidence that women who have a caesarean section may be at increased risk of complications in a subsequent pregnancy². Compared with vaginal delivery in the first pregnancy, caesarean section has been found to be associated with significantly increased rates of: uterine rupture in labour;³ placenta previa and placental abruption;⁴ placenta previa leading to peri-partum hysterectomy;⁵ stillbirth;⁶ and perinatal death⁷. Sometimes some unusual complication develops with which, we are not familiar. Here an uncommon complication following caesarean section in a post caesarean pregnancy has been reported.

Case report

A 25 years old lady P ₁₊₄ presented at the emergency department of NRS Medical College & Hospital, Kolkata as an unbooked sixth gravida with the complaint of leaking per vagina for last 4 hours and the period of amenorrhoea was 38weeks. Her past obstetric history revealed that she had caesarean section 4 years earlier (indication of caesarean section was not known to the patient) and 4 successive M.T.Ps, the last being done 1 year back. The baby was alive. The couple wanted ligation operation.

On examination, she was mildly anaemic. Pulse was 88/min and BP was 126/80 mm Hg. She was free of any medical or surgical complications like morbid obesity, COPD and umbilical hernia. Per abdominal finding revealed a term size uterus with cephalic presentation and average liquor. FHS was 144/min and regular. Her previous caesarean section scar was low transverse and there was no scar tenderness.

Per speculum examination showed dribbling of clear liquor. Vaginal examination revealed cervix was 1.5 cm dilated, tubular, station was high up (-3) and membranes were absent.

An emergency L.S.C.S. was performed under spinal anesthesia. The skin incision was Pfannenstiel with excision of the previous scar. On opening the abdomen, uterus was found to be adherent with anterior abdominal wall from which uterus was separated for delivery of the baby (a living male baby of 2.75 Kg) and bilateral tubectomy operation. Bladder was also pulled high up which was dissected and pushed down before opening the uterus. Parietal peritoneum was not closed and rectus sheath was repaired with no 1 chromic catgut. Duration of operation was one hour which was longer than usual operation time of 35 minutes.

First two post operative days were uneventful. On the 3^rd day there was a small amount of serosanguinous discharge from the umbilicus. The caesarean section wound, which was located much below the umbilicus, was healthy. Methylene blue dye was introduced into the bladder to rule out any communication with umbilicus, through which no dye came out. On 4^th post operative day a mass was seen protruding through the umbilicus and on gentle prodding it seemed to be omentum like structure (Fig-I) A provisional diagnosis of omental hernia through umbilicus was made.

Figure I showing omentum like structure protruding through umbilicus


Figure II showing omental tag held during herniorrhaphy operation

On the 5^th post operative day, she underwent herniorrhaphy operation under general anesthesia. A tag of omentum was seen to herniate through anterior rectus sheath and skin (Fig-II). The protruding tag of omentum (sent for histopathological examination and confirmed) was excised and a double breasting of rectus sheath was done, keeping a drain which was removed after 48 hours. Her subsequent recovery was uneventful. She came for check up after 6 weeks, when no abnormality was detected.

Discussion

A review of literature has failed to demonstrate the type of complication mentioned above . Intra operative complication like dense intra abdominal adhesion resulting in injury to the bladder and the bowel is not uncommon⁸. Probably this case report presents an unusual complication for the first time. Probable explanation is that during too much dissection of anterior rectus sheath (to get access to the fallopian tubes) which was firmly adherent with uterus, there was inadvertent injury to the anterior rectus sheath and skin through which omentum had protruded.

References

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