HERNIA INTO THE PREVESICAL SPACEBY IRVING J. WALKER, M.D.

OF BOSTON, MASS.FROM THE HARVARD SURGICAL TEACHING SERVICE, BOSTON CITY HOSP'TAL

Two cases of hernia into the prevesical space are reported in this paperas an addition to the small number now recorded in the literature.

Since other types of hernia have their origin in the same region, namely,the supravesical fossa, it would seem fitting that the subject of hernia ofthis space should be given some consideration.

The supravesical fossa is a triangular area bounded laterally and aboveby the lateral umbilical folds which cover the obliterated hypogastric arteries,and below by the peritoneal reflection which passes from the anterior ab-dominal wall to the fundus of the bladder. On both outer sides of thisarea are the middle inguinal fossxe.

Herniax originating in the supravesical fossa have been known for along time (Cooper, I804). They have been mentioned in the literatureunder various titles, such as that of Wilms,' prevesical; Waldeyer,2 supra-vesical; Klebs,3 anterior retroperitoneal; Kronlein,4 properitoneal; Leserand Linhart,5 inner inguinal herniae.

It is evident from these differences in terminology that the nomenclaturehas been based on various anatomical considerations. When a hernia hasoriginated within the boundaries of the supravesical fossa, it would seem rea-sonable to accept the term advocated by Waldeyer and classify it as asupravesical hernia. Further elaboration of this classification can be-made,dependent upon the structures or regions invaded by the hernia sac. Asan example, the type of hernia discussed in this paper might well be calleda supravesical hernia of the prevesical type.

The upper limit of the supravesical space in the region of the umbilicus is the tipof the angle formed by the junction of the lateral umbilical folds. In a downwarddirection the space widens between these ligaments as one approaches its lower aspect.The reflection of the peritoneum from the anterior abdominal wall backward to thefundus of the bladder marks the lower level of the fossa. Anteriorly, the space islimited by the musculature of the abdominal wall. Posteriorly, it is covered by peri-toneum. Extending from the summit of the bladder to the junction of the lateralumbilical folds is the middle umbilical plica covering the urachus. This divides thesupravesical fossa into a right and left half, sometimes termed the internal inguinalfossae. The latter vary in depth according to the prominence of the folds above men-tioned. Luttelmann" states that these folds may protrude in the fashion of a comb,each having a more or less definite mesentery. Below the peritoneum forming thelower boundary of the supravesical fossa, and lying between the bladder and the pubicbone, is a more or less triangular area known as the prevesical space or Space ofRetzius. Laterally this extends to the outer limits of the bladder. In depth it reachesto the prostate and its covering. The region is filled with varying amounts of areolartissue and fat and is subject to change in size and shape according to whether the

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bladder is filled or empty. It is with herniae into the prevesical space that we areconcerned in this paper.

Etiology.-Undoubtedly several factors enter into the etiology of thoseherniae arising in the supravesical fossa. Increased prominence of the lateraland middle umbilical folds is unquestionably a factor in the production of

PLATE I

peritoneal pockets. Rokitansky,7 according to Reich,8 was the first to callattention to the occurrence of these supravesical peritoneal pockets and tothe possibility of hernial incarceration in the same.

Also of importance in the production of these hernie is the possibilityof weakened areas in the adjacent anatomical structures. Incidentally, Luttel-mann has pointed out that individuals presenting supravesical herniae of theexternal form show a predisposition toward other types of hernia.

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If for any reason the subperitoneal fat shows atrophy, there is an addi-tional tendency for the peritoneum of the supravesical fossa to becomeinvaginated. '

Luttelmann adds another possibility by presenting the theory that apreviously existing inflammation beneath the peritoneum of this area withresulting scar-tissue contraction might result in invagination of the peritoneum.

Increased intra-abdominal pressure has been mentioned as another factorin the production of those herniae which appear upon the surface.

These herniae undoubtedly start as small peritoneal pockets aptly describedby Luttelmann as "swallow-nest" formation. They may remain as such, ormay develop by penetrating the abdominal wall, later demonstrating them-selves as external forms of hernia. Because of the anatomical structure cer-tain ones cannot ever appear upon the surface.

Where the musculature of the abdominal wall has been invaded, but wherethe sac does not appear upon the surface, this form of hernia has been termedinterstitial.

After carefully reviewing case reports, we find that hernia arising inthe supravesical fossa tend to develop in three directions, dependent uponthe part of the fossa in which the peritoneal opening is found. From thisobservation, which we do not offer as a constant rule, we can divide thesupravesical fossa into three more or less distinct regions.

The first portion is represented by the area on the peritoneum overlyingwhich is the rectus muscle. A hernia arising within this area points forwardand should there be weakness of the rectus muscle may present itself uponthe surface. In formation this may be likened to the well-known epigastrichernia; from its location, it can be termed hypogastric.The second portion is a triangular area bounded on the inner side by an

imaginary line on the peritoneum, representing the outer border of the rectusmuscle; on the outer side by the lower part of the lateral umbilical plica, andbelow by the reflection of peritoneum extending from the anterior abdominalwall to the bladder. The width of this portion varies with the width ofthe rectus muscle together with the distance between the lateral umbilicalfolds. A hernia arising in this arnea has a tendency to point laterally outwards.Should there be weakness of the abdominal wall, it may appear upon thesurface at the outer border of the rectus muscle, over or through the in-guinal falx, above the lacuna ligament or just to the inner side of the femoralopening. In most cases, such hernixe, as Roser9 and others have pointed out,carry ahead of the sac a lipomatous formation which unquestionably is afactor in their tendency to develop toward the surface. Many of these havebeen operated upon with the diagnosis of femoral hernia.

The third portion is represented by the peritoneal reflection which coversthe Space of Retzius. Hernial formation originating in this area has atendency to push downwards into the prevesical space. Because of the rigidanatomical structure, the pubic arch, on the anterior aspect of this space,such a hernia never becomes external.

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The literature reveals numerous herniae arising in the first two portions.As a matter of fact, those arising in the second portion constitute the greatestnumber of so-called herniae of the supravesical fossa.

Reich's collection of cases and description of supravesical hernia is thefirst one in the literature covering the subject. The topic has also beendiscussed by Vogeler,'0 Marconi,1' Luttelmann, Waldeyer, Watschugoff,12Bayer,13 Schiele,14 Kudrnac,'5 Brentano,16 Belu,'7 Jaehne,18 Fromme,19 andothers.

Hernia into the prevesical space, judging from the number of cases re-ported, is a rare condition. Personal interviews and communications withcertain anatomists reveal none found in the cadaver. Cases I and III ofReich, and an additional one cited by Maydl,20 are apparently the only onesreported to date, which leave little doubt as to their being herniae into theprevesical space. There are other cases which because of inadequacy ofreports and descriptions cannot definitely be considered by us to be prevesicalherniae, although certain of them may be such. Case II of Reich, as well asthe single case of Brentano, and Case II in the series of Watschugoff, fallinto this group.

To the three mentioned above we are adding two more, making a totalof five cases of hernia into the prevesical space which have been reported todate according to our findings and case interpretations.

CASES REPORTED

CASE I.-J. D., male, aged fifty-one years, entered the hospital November IO, I929,with the chief complaint of abdominal pain and vomiting. He stated that four daysbefore a left inguinal hernia which had been present for years became pinched in thetruss he was wearing. He noted pain in the region of the left external inguinal ring.The pain was cramp-like and lasted for twenty-four hours. After an interval of eighteenhours without pain, the latter recurred. There was no vomiting until six hours afterthe second onset of pain. The vomitus, at first light green in color, was later darkand of foul odor. An enema produced gas but did not relieve the pain. He had somefrequency of urination for four days preceding entrance to, the hospital.

Abdominal examination showed general distension with tenderness but no spasm.Auscultation revealed marked increase in peristalsis. Both hernial rings showedimpulses on cough, but no evidence of a strangulated hernia. By rectal examinationthere was a moderately enlarged prostate. Pulse, IIO. Respiration, 20. Temperature,99.5'. Blood-pressure, iI8/8o. White count, I2,000.

The diagnosis of acute intestinal obstruction of unknown etiology was made.Operation under spinal anaestheqia revealed an opening in the peritoneum three-

fourths of an inch in diameter to the right of the umbilical ligament just anterior tothe fundus of the bladder as illustrated in Plate I. Within this sac was a loop ofstrangulated ileum. The peritoneal edge of the sac was incised. A loop of viablebowel was removed from the, sac. The latter extended two inches downwards. intothe prevesical space. The peritoneal lining of the sac could not be evaginated. Theedge of the ring of the sac was freshened and the opening closed with a continuouscatgut suture. The convalescence was uneventful. His health has remained goodsince leaving the hospital. There has been no frequency of urination such as existedjust prior to operation.

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CASE II.--F. R., male, aged sixty-three years, was first seen in the hospital Feb-ruary 3, I930. He stated that two days previously, shortly after eating fish, he wasseized with abdominal cramps and vomiting. He had vomited off and on since then.The vomitus was at first light yellow in character but later was brown. His bowelshad not moved since the onset of pain, even with cathartics. There were no othersymptoms, other than some frequency of urination, which had been present for sev-eral years.

Physical examination was essentially negative except for the abdomen. This showedconsiderable distension with tender-ness, but no spasm, or visible peristal-sis. There was increased auscultoryperistalsis. On the right was an en-larged external inguinal ring, through

...... which a definite impulse could be felton cough. There was no evidence of astrangulated hernia. Rectal examina-

- tion was negative. Temperature, 99°.Pulse, 120. Respiration, 25. Blood-pressure, I34/80.

A pre-operative diagnosis of in-testinal obstruction of unknown originwas made, and operation advised. Ex-ploration under spinal anesthesia re-vealed no abnormality except a loopofileum strangulated within a peni-

toneal pocket near the apex of thebladder, just to the right of the um-bilical ligament. This was releasedafter a small incision was made in theperitoneal edge of the ring. The bowelwas found to be dark in color butviable. The opening of the sac wasabout one inch in diameter. The sacitself was about two inches long, ex-tending downwards anteriorly to thebladder into the prevesical space asshown in Plate II.

The edges of the ring were fresh-~~ ~~~. ~~~~ ~ened and the opening closed with a

continuous suture of catgut. BecausePLATE II of the marked toxaemia accompanying

the obstruction, a jejunostomy was done. The convalescence was uneventful. On Febru-ary 28, I930, he was cystoscoped with negative bladder findings. A cystogram wasalso negative.

Symptomatology. Since herniae into the prevesical space never demon-strate themselves upon the surface it is obvious that they will be discoveredonly incidentally in abdominal exploration or when they are attended withsymptoms of intestinal obstruction which have led to operation. It is afact that the pre-operative diagnosis of hernia into the prevesical space hasnever been made. The condition is apparently one affecting males of adultyears. One can assume, we believe, that these liernix give rise to no symp-

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toms unless a viscus is present within the sac. With incarceration orstrangulation of a viscus in a prevesical hernia, because of the proximity ofthe same to the bladder, one might expect some evidence of micturitionaldisturbance. Reich mentions that frequency of urination should be a commonfinding. However, since these cases occur in males of advanced years inwhom prostatic disease is possible, urinary frequency is likely to be at-tributed to hypertrophy of this gland. A careful history taken post-opera-tively in our cases showed that frequency was present in Case I. In thisinstance it was of short duration, was relieved by operation, and has notrecurred. In our second case the frequency could be explained by hyper-trophy of the prostate. We feel that frequency of urination in cases ofstrangulation of a viscus in a hernia into the prevesical space can be con-sidered a positive symptom of this condition, other causes of frequencyhaving been eliminated. We also think that cystoscopical examination inthe presence of a strangulated hernia into the Space of Retzius would re-veal a bulging on the anterior wall of the bladder, produced by the tumormass. Practically, such a positive finding might be of value in establishingthe exact nature of the condition causing the obstruction. On the other hand,cystoscopical examination could be criticized as possibly adding to the risk.

The symptomatology that has led to operation in all cases reported hasbeen that associated with acute intestinal obstruction. In any case, it ispossible that there may have been previous attacks of ileus which havedisappeared spontaneously. Such finding in the history should be of somesignificance in establishing the diagnosis.

The small bowel has been the strangulated viscus mentioned in all casesreported. Since the symptom complex of intestinal obstruction is so wellknown, it would seem unnecessary to further elaborate on that subject in thispaper.

Reich has emphasized the importance of the presence of tenderness overthe bladder and the presence of distended loops of intestine in the region ofthe symphysis as significant findings in the physical examination. Such ob-servations were not noted by us.

Treatment.-Regardless of the value of the positive diagnosis of astrangulated hernia into the prevesical space, the treatment becomes that ofcombating toxaemia, followed by laparotomy. At operation the viscus will befound to be constricted by the opening of the hernial sac. In our cases itwas not possible to release the intestine without first having made a smallincision in the dense edge of the peritoneum forming the ring of the sac.This having been accomplished, the intestine was readily replaced withinthe abdomen. In neither instance could we evaginate the sac with the ideaof excising it without considerable dissection, which we considered unwise inthe presence of intestinal obstruction. The procedure which we followed andwhich we advise in all such cases of strangulated but viable intestine wasrelease of the strangulated bowel, a freshening of the edges of the peri-toneum making up the ring, and a closure of the latter by a continuous

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suture. Obviously, with a non-viable viscus the operative procedure willbecome more elaborate.

The post-operative care should be directed towards treatment of thetoxaemia of the patient. Upon the degree of the latter hinges to a great ex-tent the outcome of any individual case.

SUMMARY

Hernia into the prevesical space is a rare type of internal hernia originat-ing in the supravesical fossa.

An accurate pre-operative diagnosis of hernia into the prevesical space ispossible but hardly to be expected.

The operative treatment offers no unusual problem.The prognosis depends upon the degree of toxaemia accompanying the

condition of strangulation when this is present, the ability or not to haverecognized a hernia within the prevesical space, and the operative proceduresinvolved in the individual case.

BIBLIOGRAPHY1Wilms: Der Ileus. Deutsche Chirurgie. Lieferung, 46 g., I906.'Joessel-Waldeyer: Handbuch der topographisch-Chirurgischen Anatomie mit Ein-

schluss der Operations-ubungen an der Leiche. Nach dem Tode des Verfassersfortgesetzt von W. Waldeyer, I884-I889.

3Klebs, Edwin: Handbuch der pathologische Anatomie. Bed. i, I869.'Kronlein, R. U.: Hernia inguino-properitonealis incarcerata. Arch. f. klin. Chir.,

vol. xix, pp. 408-420, I875-I876.6 Linhart, W.: Vorlesungen fiber Unterleibs-Hernien. Wiirzburg, i866.8Luttelmann, J.: Ueber supravesickale Hernien. Breslau, I9I9.7Rokitansky, Carl: Lehrbuch der pathologischen Anatomie. 3 Aufl., vol. iii, i86I.8 Reich, A.: Ueber eine neue pericoecale Hernie, die Hernie des Recessus coecalis.

Beitr. z. klin. Chir., vol. lxiv, pp. I-34, I909.9Roser, quoted by Luttelmann and Vogeler.0 Vogeler, Karl: Die supravesicalen Hernien. Beitr. z. klin. Chir., vol. cxviii, pp.

3I8-34I, I9I9.Marconi, Albert: Hernia supravesicalis-externa. Wien. Med. Woch., vol. lxx, pp.

5I2-514, 1920.2Watschugoff, A. P.: Ueber die intraabdominalen Hernien der Foveae supravesicales

auf Grund dreier eigener Beobachtungen. Deut. Zeit. f. Chir., vol. ccxxx, pp.342-344, I93I.

"Bayer, Carl: Hernia juxtavesicalis dextra incarcerata. Zentralbl. f. Chir., vol. xlix,pp. 671-673, I922.

4 Schiele, George: Hernia supravesicalis interna incarcerata. Zentralbl. f. Chir., vol.liii, pp. 1252-1254, I926.

15 Kudrnac: Hernia juxtavesicalis incarcerata dextra. Zentralbl. f. Chir., vol. liii, pp.88-89, I926.

6 Brentano: (Freie Vereinigung der chirurgen Berlins) Hernia retroperitonealisanterior sinistra. Zentralbl. f. Chir., vol. xxiv, p. 82I, I897.

7 Belu, N.: Hernia juxtavesicalis incarcerata dextra. Zentralbl. f. Chir., vol. liii, pp.1124-II25, I926.

"Jaehne, A.: Beitrag zur operativen Benhandlung der inneren Hernien. Beitr. z. klin.Chir., vol. lvi, pp. 439, 447, I907-i9o8.

9Fromme, Albert: Uber einen Fall von Hernia retroperitonealis anterior sinistraincarcerata. Deut. Zeit. f. Chir., vol. xcii, pp. 365-37I, I908.

' Maydl, K.: Die Lehre von den Unterleibsbruchen, I898.

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