internal hernia

2. DEFINITION
 An internal hernia is defined as the protrusion of viscera
through a normal or abnormal opening within the
boundaries of the peritoneal cavity.
Hernial orifice may be
preexisting anatomic structure, a pathologic defect
such as the foramen of Winslow, congenital or acquired
origin

3. TYPES
 Foramen of winslow
 Paraduodenal (MC)
 pericecal, retrocaecal,
 transmesenteric,
 intersigmoid, and
 paravesical hernias.

4. PARADUODENAL HERNIA

5. PARADUODENAL HERNIA
Pathogenisis:
1)Increased intraabdominal preasure pushes the
bowel into potential sac
2)Congenital anomaly in development of
peritonium that arises during midgut rotation
Types
Rt paraduodenal
lt paraduodenal

6. PARADUODENAL HERNIA(lt)
Lt.paraduodenal hernia
Ant Part of orifice is
IMV,post part is post abd
wall,contains most of small
bowel
Afferent limb-4th part of duo
Efferent limb-terminal part
of ileum.

7. PARADUODENAL HERNIA(rt)
Here the ant part of
hernia is sup mesentric
artery

8. Symptoms
 Acute or intermittent small bowl obstruction
pain,vomiting,distention,obstipation.
 Investigations
X ray abdomen
CT abdomen
D lap
 Treatment
Basic principles of hernia surgery, including reduction of the
hernia contents, resection of the hernia sac, restoration of
normal bowel anatomy, and repair of the hernia defect

9. TREATMENT
If the small bowel is edematous, the hernia orifice is
tight, or adhesions within the sac prevent manual
reduction of the contents, the hernia orifice can
be widened by excising the avascular plane to the right
of the IMV. Care should be taken to avoid damage to
this structure and the left colic artery, both of which lie
in close proximity to the anterior edge of the orifice.

10. Transmesentric hernia
Protrusion of a loop of bowel through
the mesentery of the small bowel, the
transverse mesocolon, the sigmoid
mesocolon, or the falciform ligament.
Congenital-associated with intestinal
atresia, or mesenteric ischemia,
Acquired-Most TMHs in adults are
related to predisposing factors,
including previous surgery, abdominal
trauma, and peritonitis.

11. Symptoms
 Features of acute intestinal obstruction, rapidly
progress into shock if associated with mesenteric
ischemia and bowel necrosis.
 Diagnosis
CT shows Mesenteric vessels may be stretched,
crowded, engorged, and have a “whirl sign.”

12. Treatment
 Nasogastric decompression, aggressive preoperative
fluid replacement, and correction of electrolyte
disturbances are essential before surgical exploration.
Abdominal exploration is mandated in all cases of
TMH given the high incidence of incarceration and
strangulation.

13. TRANSOMENTAL HERNIA
Herniation of viscera,typically small
bowel, through an opening in the
gastrocolicomentum. The ring is
formed entirely by the omentum.
cause of the omental rent is unknown,
but inflammatory, traumatic, circulatory,and congenital
mechanisms have all been implicated.

14. Treatment
 Releasing the constricting ring by incising the
omentum between clamps
 resecting or reducing the bowel, depending on its
viability.

15. Hernia through epiploic
foramen(Blandin hernia)
Aetiology
large epiploic foramen,
mobile cecum and ascending colon
Contents
small bowel (63%);
cecum and right colon (30%);
transverse colon (7%)
gallbladder can also herniate

16. Treatment
 If the orifice is large reduce the hernia
 If the orifice is narrow and associated with edematous
bowel loops the best option is controlled
decompression of the distended bowel to avoid the
vital structures that pass through the hepato duodenal
ligament
 Fixation of the caecum can be done
 Usually here closure of the opening are not generally
recommended,

17. Intersigmoid
Here the orifice related to
Lt Ureter,iliac vessels

18. Pericaecal,retrocaecal hernia

19. Retrocaecal hernia(hernia of Rieux)
 caused by a partial defect of fixation of the right
ascending mesocolon (Toldt fascia). In this type
of hernia, the viscera are trapped between the
abdominal posterior peritoneum on the dorsal side,
the cecum ventrally,and the right ascending
mesocolon as the upper limit.

20. PERICAECAL HERNIA
 Superior ileocaecal hernia:
In sup ileocaecal fossa formed by fold in sup
ileocolic mesentry it contains ant branch ileocolic
artery here the hernia sac travels under the right
mesocolon.
 Inferior ileocaecal:
The inferior ileocecal fossa has a prominent
anterior ileoappendicular fold. This fold occasionally
contains the ileoappendicular artery. The hernial sac is
found under the cecum.

21. Acquired internal hernia
Hernia in iatrogenically created defeact:
1)open and laparoscopic Roux-en-Y gastric bypass,
2)Billroth II gastrojejunostomy,
3)bilioenteric anastomosis,
After the gastric bypass the hernia occur in 3 iatrogenically
created space
1) the transverse mesocolon,
2)the divided small bowel mesentery,
3)the Petersen space that is located between the small
bowel mesentery of the Roux limb and the transverse
mesocolon.

22. Acquired internal hernia
The mesocolic defect (arrow A),
The Petersen defect (arrow B), a
The enteroenterostomy defect
(arrow C).

23. Roux en y gastric by pass

24. Diagnosis
 Gastric bypass patient with symptoms
of nausea, vomiting, abdominal distention, and
colicky postprandial abdominal pain should raise the
suspicion of an internal hernia
CT Shows: Mesenteric swirl sign

25. Diagnosis
 Gastric bypass patient with symptoms
of nausea, vomiting, abdominal distention, and
colicky postprandial abdominal pain should raise the
suspicion of an internal hernia
CT Shows:Mesenteric swirl sign

26. Treatment
 Confirmation by Diagnostic laparoscopy.
 Reduction of hernia by laparoscopy or open method
 Closure of defect by non-absorbable suture

27.  High index of clinical suspicion along with prompt
surgical management is required in internal
hernia in order to avoid a potential abdominal
catastrophe.
THANK YOU
….
Reference: Shackelford, internet