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Paper text:
an abdominal wall hernia is an abnormal protrusion of a peritoneal - lined sac through the muscolo - aponeurotic covering of the abdomen and different types of hernias can be classified in dependence of herniation 's region . to understand the pathophysiology of abdominal 's hernias
the rectus sheath is composed of the aponeuroses of the transversus abdominis , the external- and internal - oblique muscles , and completed by the transversalis fascia , that contains the rectus abdominis muscle .
the sheath is constituted of anterior and posterior layers : the anterior layer is composed by the external oblique aponeurosis , the anterior lamina of the internal - oblique aponeurosis and in the inferior quarter also from the transversus abdominis aponeurosis .
the posterior layer is made up of the posterior lamina of the internal - oblique aponeurosis , the transversus abdominis aponeurosis and the transversalis fascia in the three superior quarters and only of the transversalis fascia in the inferior quarter : between these two regions there is a line with an inferior concavity , called the linea arcuata ( la ) .
an ascending protrusion of intraperitoneal structures over the la is denominated linea arcuata hernia ( lah ) . in this region , because of the deficiency of the aponeurotic fibers , the abdominal wall is made up only of the transversalis fascia : this zone of weakness is the major factor that could develop a parietal herniation . additionally with this anatomic weakness , any condition increasing the intra - abdominal pressure , plays a pivotal role in the development of abdominal hernias ( i.e. constipation , obesity , chronic obstructive pulmonary disease , pregnancy ) .
the prevalence of lah is unclear , the underlying reason is that most of lah are asymptomatic and remain unclassified , the diagnosis is often incidental or could be misclassified by another abdominal hernia .
a limited number of studies in the literature describe a symptomatic hernia of la ; no studies reporting the risk factors associated with lah or clear descriptions of techniques for repair , and overall there are no cases of lah in post - cesarean period described in the literature .
we aimed to report the case of a patient with an la strangulated hernia without necrosis , 2 weeks post - cesarean section through pfannenstiel incision .
we report a case of a 46-year - old adipose woman , presented to the emergency department ( ed ) with a significant abdominal pain accompanied by two episodes of vomiting .
two weeks previously the patient had had a twin birth : the first born was vaginally and the second one by cesarean section with pfannenstiel incision ; the postoperative recovery after the delivery was uneventful .
the clinical examination at the ed demonstrated a mildly distended abdomen in the lower quadrants with regular bowel movements .
clinically , an incisional hernia through the pfannenstiel was suspected , for exclude it an abdominal computed tomography ( ct ) scan has been completed .
this examination showed a hernia of the small intestine through the transversalis fascia and the rectus sheath , without radiological signs of strangulations .
the open laparotomy was done through the pfannenstiel incision : the exploration did not show any hernia 's defect in this zone ; a major revision of the preperitoneal space revealed an herniation up to the pfannenstiel incision at the lower limit of the posterior layer of the rectus sheath , and a midline laparotomy was necessary .
the hernial sac was opened and the intestinal loops inside were reduced into the abdomen without resection .
she has been alimented with a good tolerance and the postoperative pain has been successfully managed by a classic painkiller .
the patient could be discharged by postoperative day 7 . a follow - up 2 weeks postoperative at her obstetrician - gynecologist showed a fully recovered patient , free of complaints and a healed wound with minimum scarring .
we report the case of a 46-year - old patient who consulted the ed , 2 weeks after a twin birth because an abdominal pain in the lower quadrants accompanied by vomiting episodes . after completing an abdominal ct scan
the lah is rare , just seven cases of lah are reported in the literature , as described by montgomery et al . in their review in 2012 .
in fact , the prevalence of lah in the literature was reported only by coulier with his retrospective study of 315 abdominal ct scan of unselected symptom - free patients : the lah 's prevalence was 8.57% , though reached 14.97% in men , and a relative male : female sex ratio of 12.5:1 . according to coulier
, the male gender seems to be a risk factor associated to lah . as for the prevalence
, the literature has not invested studying the risk factors of lah . except the male gender ,
just the known factors that increased intra - abdominal pressure ( i.e. constipation , obesity , chronic obstructive pulmonary disease , pregnancy ) , which plays a pivotal role in the development of generally all abdominal hernias types , are considered . despite the well - known risk factor for the development of the hernias of the abdominal wall
is pregnancy , no diagnosis of lah after a vaginal delivery or cesarean section , conform our case , is reported in the literature .
we speculate that the low interest of the literature for the lah is due to her low prevalence , probably caused by the fact that the lah is often not diagnosed , because asymptomatic . as well as the factor that lah remains unrecognized because it has no clinical impact in the majority of cases ; therefore , no investigation is sought .
we find similar evidence in coulier 's analysis : in his retrospective study of 315 abdominal ct scan of unselected symptom - free patients : in 27 of them the abdominal ct demonstrated fortuitously the lah .
moreover , even when an lah is symptomatic , her diagnosis is difficult and the reason why because her symptomatology is a specific and to localize the hernia using only the clinical examination is quite difficult .
an important role that increases the diagnostic accuracy could be the utilization of the radiologic examinations : abdominal us and especially abdominal ct scan .
in fact three of the seven cases reported in the literature were correctly diagnosed by ct .
consistent is coulier 's study , where he provides compelling evidence that the ct scan helps distinguish the diagnosis of lah in a significate number of patients , especially in old men .
although imaging is contributively , it remains complex and challenging to diagnose lah : indeed also with the help of radiologic examinations , the lah is misdiagnosed as the others abdominal wall 's pathologies , especially as a spigelian hernia .
von meyenfeldt et al . reported two cases of lah : the first case was a 53-year - old man with a left - sided paramedian bulge of the abdominal wall , which was incorrectly interpreted as a spigelian hernia during an ultrasound ( us ) examination .
the second case was a 41-year - old man with a left - sided paramedian abdominal bulge at the level of the umbilicus .
since the us examination appeared to be inconclusive , a ct scan was executed and misdiagnosed an lah as a spigelian hernia .
also in our case , the ct scan induced the misdiagnosis of an incisional hernia of the pfannenstiel scar , and the correct diagnosis was only identified in the operating room .
the lah is an underestimated pathology and difficult to diagnose , although contributively and highly recommended , the radiologist could not enable meaningful conclusions by means of the ct scan as in our case .
this highlights the possibility of a missed lah by imaging and shows the importance of at least considering an lah in the differential diagnosis of the acute abdominal pain , especially with risk factors , like pregnancy or puerperium .
we report a rare case of a 46-year - old woman 2 weeks after a cesarean section with pfannenstiel incision , who presented at the emergency department with a significant abdominal pain accompanied by two episodes of vomiting . 
 after that a clinical examination and an abdominal computed tomography scan were completed , a visceral herniation through pfannenstiel incision was suspected . 
 the indication of surgical exploration was clear . 
 finally , the laparotomy revealed a linea arcuata hernia with a hernia of the small intestine . 
 after a reduction of the hernia sac , the defect was repaired and no mesh was placed . an antibiotic treatment with co - amoxicillin for 1 week during the recovery 
 was prescribed . 
 the patient recovered uneventfully and could be discharged by postoperative day 7 .