Littre Hernia

A Littre hernia contains a Meckel diverticulum within the hernia sac.

It may occur in inguinal, femoral, umbilical or other abdominal wall hernias.

The diverticulum can become incarcerated or strangulated even when the remainder of the ileal lumen remains patent. Complete bowel obstruction is therefore not obligatory.

Complications include diverticulitis, ischaemia, perforation, ulceration from ectopic gastric mucosa and rarely neoplasia within the diverticulum.

Most cases present as an acutely painful irreducible hernia.

Vomiting and abdominal distension may occur when adjacent small bowel is also obstructed.

Because only the diverticulum may be trapped, a patient can have local strangulation without complete bowel obstruction.

Increasing local tenderness, overlying erythema, systemic toxicity or peritonitis suggests infarction or perforation.

Preoperative diagnosis is uncommon.

CT abdomen and pelvis: may identify a blind ending bowel structure arising from distal ileum within the hernia sac, but many cases are recognised only during surgery.

Operative treatment is required for an incarcerated Littre hernia.

Reduce the hernia carefully and inspect the Meckel diverticulum together with the adjacent ileum.

Resect the diverticulum when it is inflamed, strangulated, ischaemic, perforated, bleeding or otherwise pathological.

A simple diverticulectomy is appropriate when:

• The base is narrow and healthy
• Adjacent ileum is clearly viable
• There is no concern that pathology extends into the ileal wall

Perform segmental ileal resection with primary anastomosis when:

• The diverticular base is broad
• Ischaemia involves adjacent ileum
• There is perforation close to the base
• Significant inflammation involves the ileal wall
• Tumour is suspected

An incidentally discovered completely normal Meckel diverticulum within a hernia can reasonably be resected because its presence within the hernia has already demonstrated abnormal mechanical behaviour, although operative contamination and individual patient risk should still be considered.

Repair the hernia after the bowel problem has been addressed.

Permanent synthetic mesh is appropriate when the field remains clean. Diverticular perforation, pus or gross enteric contamination should favour tissue repair or delayed definitive reconstruction rather than permanent synthetic mesh in a contaminated field.