2. 21 year old lady presented with abdominal
pain for 4 days, constipation for 3 days ,
vomiting and fever for 1 day
Past history- no surgical intervention in the
past.
Menstrual history- h/o irregular
menstruation. Last menstrual period 4
months back.
3. Patient conscious
oriented,hydration
normal
P R -98/ minute
BP 100 70 mm Hg
Afebrile
P/A - guarding + ,
tenderness + mainly
in epigastrium and
right iliac fossa
DRE- nothing
contributory
8. -Dilated duodenum jejunum and proximal ileum with
abrupt narrowing of distal ileum.
Ileal loops distal to obstruction appears collapsed.
Mesenteric lymphadenopathy present.
Moderate free fluid in peritoneal cavity.
Right moderate and left mild pleural effusion
9. Pateint was catheterised, nasogastric
aspiration done.
Exploratory laparotomy done- Intraop
finding-Defect in mesentery of 3*2 cm
through which distal ileum (about 10 cm of
bowel loop) from about 5 cm from
ileocaecal junction was found herniating
through rent in mesentery.
Vascularity of bowel loops normal.
Rest of bowel loops normal.
12. Post operative period was uneventful .
orals started on post operative day 2
No wound infection
Patient was discharged on 5th day
13. Internal hernia is protrusion of viscera
through a normal or abnormal opening within
the boundaries of peritoneal cavity.
Infrequent cause of small bowel obstruction.
The orifice can be congenital
(foramen of Winslow or from an abnormality
arising as a result of anomalies of internal
rotation
the other main group is acquired (post
operative, traumatc,post inflammatory)
14. Congenital internal hernia arises from
malrotation of midgut during embryonic
period.
Paraduodenal hernia is the most common type
of internal hernia,
more common the left side
Other types are peri caecal,
foramen of winslow,
transmesenteric,
trans mesocolic,
intersigmoid and retro anastamotic.
15. PATHOGENESIS-left PDH
Andrews-result of congenital anomaly in
development of peritoneum that arises during
midgut rotation.
Peltier et al –aquired or related to anomalous
rotation of midgut
Right PDH
Abnormalities of second phase of embryonic
intestinal rotation,resulting in arrest of further
rotation of prearterial segment of gut in right side
of abdomen.
16. Symptoms-non specific intermittent
abdominal pain to acute SBO. pain
exacerbated during eating and postural
changes, relieved by alterations in position
mainly by lying supine .
DIAGNOSIS- CT –encapsulated bowel loops
at or above ligament of Treitz,a mass on
posterior stomach wall, mesenteric vessel
abnormalities and depression of transverse
colon.
17. Protrusion of loop of bowel through the
mesentery of small bowel , transverse
mesocolon,pelvic mesocolon or falciform
ligament
More common in children associated with
intestinal atresia or mesenteric ischaemia and
occurs near ligament of treitz or the
ileocaecal valve.
In adults it is related to previous
surgery,abdominal trauma and peritonitis.
18. -severely ill,
may progress to a shock like state,
palpable abdominal mass,
localised succession splash may be elicited
over it
19. may show cluster of small bowel loops ,
SBO,and central and posterior displacement
of colon.
mesenteric vessels may be stretched crowded
engorged and
have a whorl sign
20. TREATMENT
nasogastric decompression
,preoperative fluid replacement
and correction of electrolytes.
Abdominal exploration is mandatory in all
cases of TMH due to high incidence of
incarceration and strangulation.
If bowel loop is gangrenous ,resection
should be done,if viable,reduction of
incarcerated loops and repair of the defect
with interrupted non absorbable suture is
recommended.
21. Herniation of viscera typically small through
opening in gastrocolic omentum.
Ring is formed entirely by omentum
INTERNAL DOUBLE OMENTAL HERNIA-
Herniation of small bowel through an opening
in the gastrocolic omentum and exit through
gastrohepatic omentum
22. PREDISPOSING FACTORS
large epiploic foramen
mobile caecum and ascending colon
3 types
small bowel herniation
caecum and R colon
transverse colon
23. SURGICAL MANAGEMENT
reduce hernia,manage herniated bowel
loop,and epiploic foramen.
If reduction is difficult,
controlled decompression should be done
24. Due to viscera herniating through surgically
created defect.
Following Roux en y gastric bypass, BillrothII
gastrojejunostomy, bilioenteric anastomosis.
Presence of mesenteric swirl sign is the most
predictive sign of internal hernia
Presence of SBO with engorged mesenteric
nodes was found to be 100 percent specific
in predicting internal hernia.
