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JAMA Surgery Clinical Challenge
September 2014

An Unusual Hernia

Author Affiliations
  • 1Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
JAMA Surg. 2014;149(9):989-990. doi:10.1001/jamasurg.2013.4851

A 68-year-old woman presented 1 year after noticing a flank bulge that developed following a forceful coughing episode. Her medical history included gastroesophageal reflux disease, irritable bowel syndrome, hypothyroidism, hypertension, asthma, and obesity. On palpation, the mass extended superiorly to the costal margins and inferiorly to the anterior-superior iliac spine; no fascial edge was palpable medially. A computed tomographic (CT) scan demonstrated abdominal contents—including liver, ascending colon, and omental fat—protruding through a 12-cm defect. Weight loss was counseled and 8 weeks allowed for optimization before exploration. On incision, we encountered this view (Figure 1).

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