Case Report

Incisional Hernia of Gallbladder in a Patientwith Gallbladder Carcinoma:Sonographic Demonstration

Masafumi Shirahama, MD,1 Shingo Onohara, MD,1 Yuichi Miyamoto, MD,1 Akihiro Watanabe, MD,2

Hiromi Ishibashi, MD3

1 Department of Internal Medicine, Saga Prefectural Hospital, Saga, Japan2 Department of Surgery, Saga Prefectural Hospital, Saga, Japan3 First Department of Internal Medicine, Faculty of Medicine, Kyushu University, Fukuoka, Japan

Received 30 July 1996; accepted 5 February 1997

Incisional hernia is a true iatrogenic hernia. Itsformation is a common complication of abdomi-

nal and flank wounds, but it is extremely rarethat the gallbladder is the organ involved. Wedescribe a case in which protrusion of the gall-bladder through the endoabdominal fascia wasdemonstrated by sonography in a patient withgallbladder carcinoma.

CASE REPORT

A 71-year-old woman was admitted to our hospi-tal with a tender mass in the right upper quad-rant. She had no fever. She had occasionally suf-fered from right upper quadrant pain for 1 year.On physical examination, spider angiomas on theanterior chest and an oblique surgical scar in theright upper quadrant were seen. The patient’smedical history included a cholecystotomy forcholelithiasis at the age of 42. Upon palpation,her liver was found to be elastic and hard, with anuneven surface, and a soft, round, and tendermass about 6 cm in diameter was felt in the rightupper quadrant.

Laboratory data were as follows: hemoglobinlevel, 12.4 g/dl; white blood cell count, 3,300/ml;platelet count, 57,000/ml; glutamic-oxaloacetic

transaminase serum level, 25 U/l; glutamic-pyruvic transaminase serum level, 17 U/l; totalbilirubin level, 1.5 mg/dl; cholinesterase level,4,410 IU/l (normal, 4,250–7,250 IU/l); and CA19-9level, 276.2 U/ml (normal, <37 ml).

Abdominal sonography using a 3.5-MHz trans-ducer demonstrated a 4-cm × 3-cm subcutaneouscystic mass adjacent to the enlarged gallbladder(Figure 1). The gallbladder contained fluid, somenonshadowing internal echoes, and sludge. Thegallbladder wall was not thickened. No definitecommunication between the gallbladder and thecystic mass could be demonstrated. Additionally,a 4.0-cm × 2.5-cm echogenic mass with an irregu-lar contour was noted at the neck of the gallblad-der. The common bile duct was not dilated.

Real-time sonography using a 7.5-MHz trans-ducer revealed a pinhole communication betweenthe cystic mass and the gallbladder throughwhich an alternating, bidirectional, jet-like flowwas observed in synchronism with the patient’srespiration (Figure 2). Moreover, the cystic masshad a wall structure resembling that of the gall-bladder.

Contrast-enhanced computed tomographydemonstrated an hourglass-shaped gallbladderwith an enhancing mass at the neck and a fundusthat protruded into the abdominal wall (Fig-ure 3).

The patient underwent laparotomy, which con-firmed the diagnosis of incisional hernia of thegallbladder and coincidentally revealed gallblad-der carcinoma.

Correspondence to: Dr. Shirahama, Department of InternalMedicine, Saga Prefectural Hospital, 1-12-9 Mizugae, Saga840, JapanJ Clin Ultrasound 25:398–400, September 1997

© 1997 John Wiley & Sons, Inc. CCC 0091-2751/97/070398-03

398 JOURNAL OF CLINICAL ULTRASOUND

FIGURE 2. Longitudinal sonograms of the gallbladder using different 7.5-MHz transducers. The cystic mass isin communication with the gallbladder through a pinhole (arrows) through which an anechoic, bidirectional,jet-like flow is seen (arrowheads) against an echogenic background of biliary sludge.

FIGURE 1. Montage of contiguous longitudinal sonograms of the gallbladder using a 3.5-MHz transducer. Thegallbladder contains tumefactive sludge (small arrows) and a mildly echogenic soft-tissue mass at its neck(large arrows). A cystic mass (arrowheads) in the abdominal wall is in contact with the fundus of the gall-bladder.

INCISIONAL HERNIA OF GALLBLADDER

399VOL. 25, NO. 7, SEPTEMBER 1997

DISCUSSION

Herniation of the gallbladder alone is rare. Only afew case reports describing herniation of the gall-bladder through the foramen of Winslow havebeen published.1,2

Incisional hernia, which results from the com-bination of anatomic defects in the abdominalwall muscle at the site of a surgical wound andincreased intra-abdominal pressure, is a verycommon condition. The incidence of incisionalhernias parallels the frequency of abdominal sur-gery and is high in countries such as the UnitedStates, where about 115,000 incisional hernia re-pairs are done per year.3 However, incisional her-nia involving the gallbladder alone is extremelyrare. To the best of our knowledge, only a singlecase has been previously reported in the litera-ture.4

The mechanism for development of incisionalhernia of the gallbladder in our case is thought tobe as follows. The carcinoma of the gallbladderneck, located just proximal to the cystic duct, ob-structed the outlet of the gallbladder and led togallbladder distention. This gallbladder disten-tion, along with marked splenomegaly associatedwith liver cirrhosis, resulted in increased intra-abdominal pressure, which increased the risk forthe development of an incisional hernia.

On initial sonograms, performed with a 3.5-MHz transducer, the herniated portion of the

gallbladder appeared as a cystic mass presumedto have developed in the subcutaneous tissues orthe abdominal wall. The key to the sonographicdiagnosis of incisional hernia of the gallbladder inour case was the demonstration of the pinholecommunication between the gallbladder and thesubcutaneous cystic mass. We did not have anopportunity to apply color Doppler sonography,but we could observe an anechoic jet-like flowpassing through the pinhole communication,which stood out clearly against the low-levelbackground echoes of the biliary sludge. If thegallbladder had had a normal echo-free content, itmight have been impossible to detect this flow onthe gray-scale images. In that instance, colorDoppler imaging would have been necessary todemonstrate the flow.

Although the differential diagnosis of an an-echoic to hypoechoic mass of the abdominal wallincludes cysts (eg, epidermoid, dermoid, or othercysts), rectus sheath hematomas, and abscesses,demonstration of definite communication be-tween a cystic mass and the gallbladder wouldconfirm a diagnosis of incisional hernia of thegallbladder. The possibility of an anomaly of thegallbladder such as phrygian cap, hourglass de-formity, or duplication must be excluded. In theseconditions, the gallbladder lies in the peritonealcavity, not in the abdominal wall.

The possibility of incisional hernia of the gall-bladder must be kept in mind when a suspiciouscystic mass contiguous to the gallbladder is en-countered near a surgical scar.

REFERENCES

1. Borkar BB, Whelan JG Jr, Creech JL: Herniation ofthe gallbladder through the foramen of Winslow.Dig Dis Sci 1980;25:228.

2. Bach DB, Satin R, Palayew M, et al: Herniation andstrangulation of the gallbladder through the fora-men of Winslow. AJR Am J Roentgenol 1984;142:541.

3. Knol JA, Eckhauser FE: Inguinal anatomy and ab-dominal hernias. In Greenfield LJ, Mulholland MW,Oldham KT, et al, eds: Surgery, 1st edn. Philadel-phia, JB Lippincott Company, 1993, p. 1081.

4. Carragher AM, Jackson PR, Panesar KJ: Subcuta-neous herniation of gallbladder with spontaneouscholecystocutaneous fistula. Clin Radiol 1990;42:283.

FIGURE 3. Contrast-enhanced computed tomography scan demon-strating herniation of the gallbladder into the abdominal wall. Arrow-heads indicate the herniated portion of the gallbladder.

SHIRAHAMA ET AL.

400 JOURNAL OF CLINICAL ULTRASOUND