What type of hernia is characterized by the involvement of a Meckel's diverticulum (congenital anomaly of the small intestine) and presents with a history of reduction and irreducibility, starting in the inguinal canal with part of the small bowel remaining?

Littré's Hernia (Answer: C)

This clinical scenario describes a Littré's hernia—defined as a Meckel's diverticulum contained within a hernia sac, typically presenting in the inguinal region with features of incarceration and difficult palpation due to the diverticulum's partial bowel wall involvement.

Defining Characteristics

Littré's hernia occurs when a Meckel's diverticulum (the most common congenital anomaly of the small intestine) becomes trapped within a hernia sac, most commonly inguinal hernias. 1, 2 This entity is:

• Rare, occurring in only 1% of all Meckel's diverticulum cases 2
• Clinically indistinguishable from standard hernias containing small bowel preoperatively 1
• Difficult to palpate because only part of the bowel wall (the diverticulum) is involved, not the entire circumference 1, 3

Why Other Options Are Incorrect

Richter Hernia (Option A)

• Involves only the antimesenteric border of the bowel wall, not a congenital diverticulum
• Can occur with any segment of bowel, not specifically associated with Meckel's diverticulum

Amyand Hernia (Option B)

• Specifically refers to the appendix within an inguinal hernia sac
• Not related to Meckel's diverticulum or small bowel

Obturator Hernia (Option D)

• Occurs through the obturator foramen, not the inguinal canal
• Does not start in the inguinal canal as described in the scenario

Clinical Presentation and Diagnosis

The scenario's key features align perfectly with Littré's hernia:

• Long history of reduction attempts with current irreducibility suggests incarceration of the diverticulum 1, 3
• Difficult to palpate because the Meckel's diverticulum represents only a portion of the bowel wall, making it less prominent than full-thickness bowel herniation 1
• Starting point in the inguinal canal is the most common location for Littré's hernia 1, 2
• Part of small bowel remains refers to the diverticulum itself, which is an outpouching of all layers of the intestinal wall 1

Diagnostic Challenges

Preoperative diagnosis is unlikely because the clinical presentation mimics any hernia containing gut. 1, 2 The diagnosis typically requires:

• High index of suspicion based on clinical features 4
• CT imaging may show features of strangulation including reduced wall enhancement 3
• Definitive diagnosis is usually made intraoperatively during hernia repair 1, 2

Management Implications

Surgical resection of the Meckel's diverticulum is critical to avoid recurrent complications, followed by standard hernia repair. 1, 2 The approach includes:

• Wedge resection or segmental small bowel resection containing the diverticulum 1, 2, 3
• Standard fascial defect repair after diverticulum resection 1
• Assessment for bowel viability if strangulation is present, as ischemic changes may extend beyond the diverticulum 3