Internal Hernias

By Islam Magdy

internal hernia is an acute or chronic protrusion of a viscus through a mesenteric or peritoneal opening. These mesenteric and visceral peritoneal defects are Congenital(foramina, recesses and fossae). Acquired due to surgery, trauma, or inflammatory processes. The incidence is only 0.2-0.9%. Internal hernia is a rare cause of small bowel obstruction.(0.6-5.8%)

Peritoneal fossae develop between the 5th and 11th gestational week due to an incomplete fusion of the posterior parietal peritoneum and the posterior abdominal wall

Anatomy

Duodenal fossae
Superior duodenal Inferior duodenal(fossa of Treitz) Paraduodenal(fossa of Landzert) Intermesocolic(fossa of Broesike) Mesentericoparietal(foss a of Waldayer)

Foramen of Winslow
The lesser sac and the greater peritoneal cavity communicate through the epiploic foramen of Winslow.

This foramen is located anterior to the inferior vena cava and posterior to the hepatoduodenal ligament, including the portal vein, common bile duct, and hepatic artery .

Caecal recesses

Intersigmoid recess

Internal hernias

Congenital

acquired

Paradudenal Periceacal

Hernia of Foramen of winslow

Inter sigmoid

commonly described with Rouxen-Y formation in gastric bypasses for bariatric surgeries Liver transplantation Post anastomotic

TYPES OF INTERNAL HERNIA

A Paraduodenal:-53% B Foramen of winslow:8% C Intersigmoid:-6% D Pericaecal:-13% E Transmesenteric:-8% F Retroanastomotic-5% G Transomental:-1-4% H Supravesical & Pelvic:6%

CLINICAL PRESENTATION
Clinical symptoms may range from intermittent and mild digestive complaints to acute-onset intestinal obstruction. Internal hernias are silent if they are easily reducible, but the majority often cause epigastric discomfort, periumbilical pain. Recurrent episodes of intestinal obstruction . Internal hernias are clinically apparent only when obstruction and strangulation occurs.

Left Paraduodenal Hernia

Most common 40% Develops through the fossa of Landzert an aperture present in approximately 2% of the population The fossa of Landzert is located at the duodenojejunal junction, which is a zone of confluence of the descending mesocolon, transverse mesocolon, and small bowel mesentery

Left paradoudenal hernia

CT FINDINGS
Abnormal cluster or saclike mass of dilated small bowel loops lying between the pancreas and stomach to the left of the ligament of Treitz Mass effect on the posterior stomach wall , engorgement and crowding of the mesenteric vessels with frequent right displacement of the main mesenteric trunk, and depression of the transverse colon

Right Paraduodenal Hernia

Right PDH involves the fossa of Waldeyer which is located immediately behind the superior mesenteric artery and inferior to the transverse segment of the duodenum

Foramen of Winslow Hernia

Enlarged foramen of Winslow. An abnormally long small-bowel mesentery Persistence of the ascending mesocolon allowing marked mobility of bowel Elongated right hepatic lobe (such as a Riedel's lobe), which is thought to direct the mobile intestinal loops toward the foramen of Winslow . An ascending colon that is not fused to the parietal peritoneum.

CT FINDINGS
Presence of mesentery between the inferior vena cava and main portal vein. An air-fluid collection in the lesser sac with a beak directed toward the foramen of Winslow. Absence of the ascending colon in the right gutter Two or more bowel loops in the high subhepatic spaces

Transmesenteric Hernias
In adults,most mesenteric defects are probably the result of surgery, trauma, or inflammation. Retrocolic type of Roux-en-Y anastomosis is more associated with the potential complication of transmesenteric internal hernia.

Transomental Hernia
Two types: 1) Herniation occurs through a free greater omentum; this type is more common. No sac is present The hernial orifice on the greater omentum is located in the periphery near the free edge. 2) Herniation into the lesser sac occurs through the gastrocolic ligament .Rare

periceacal
most commonly the herniated loop consists of an ileal segment protruding through a defect in the cecal mesentery and extending into the right paracolic gutter. Clinical diagnosis is difficult Diagnoses are confused with inflammatory bowel disease, appendiceal disorders.

Sigmoid Mesocolon Hernia

Transmesosigmoid hernia Incarceration of small bowel loops through a defect in the sigmoid mesocolon. Transmesosigmoid hernia involves both layers of the sigmoid mesentery and allows herniation of the small bowel loops toward the left lower abdomen, posterior-lateral to the sigmoid colon.
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surgical Treatment
Reducing the hernia.
Resection and Primary anstomosis of bowel if not viable. Repairing the defect.

Thank you