SECTION EDITOR: CARL E. BREDENBERG, MD
Author Affiliations: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
A 49-year-old woman presented to the emergency department with a 2-day history of epigastric pain and malfunctioning of her peritoneal dialysis (PD) catheter. Her medical history was significant for sarcoidosis, end-stage renal disease secondary to focal segmental glomerulosclerosis associated with sarcoidosis, and hypertension. Her surgical history included a failed live-donor renal transplant and open and laparoscopic PD catheter placements. She had been on continuous ambulatory PD (CAPD) without any complications for a year since her last catheter had been placed. Her daily medications included prednisone, metoprolol succinate, nifedipine, clonidine hydrochloride, and multivitamins. Physical examination revealed a well-healed hockey stick scar in the right lower quadrant from her previous renal transplant, a well-healed infraumbilical scar from her laparoscopic PD catheter placement, and an obvious defect in the right paramedian portion of her upper abdomen underlying a previous incision, containing a mass and a palpated cordlike structure. Laboratory tests showed elevated levels of serum creatinine (9.9 mg/dL; reference range, 0.5-1.2 mg/dL; to convert to micromoles per liter, multiply by 88.4) and blood urea nitrogen (52 mg/dL; reference range, 7-22 mg/dL; to convert to millimoles per liter, multiply by 0.357). Computed tomography with intravenous contrast demonstrated a 3.1 × 2.0-cm right paramedian hernia (Figure 1).
Figure 1. Contrast-enhanced axial computed tomographic slice demonstrating a right paramedian hernia.
A. Hernia adjacent to PD inner cuff site
B. Hernia containing PD catheter
C. Hernia containing omentum and right gastroepiploic artery
D. Hernia containing foreign body from previous surgery
Pappou EP, Velopulos C, Fishman EK, Haut ER. Image of the Month—Quiz Case. Arch Surg. 2012;147(11):1065–1065. doi:10.1001/archsurg.2011.2043a