Internal Hernia Research Articles

Occlusion By Transmeso - Internal Hernia Congenital Sigmoid: About A Case

Internal hernia through a meso-sigmoid defect or hernia Transmesosigmoid is a rare cause of acute intestinal obstruction. Its diagnosis is most often made intraoperatively. Knowledge of its clinical particularities makes it possible to consider the preoperative diagnosis. We present 1 case of acute intestinal obstruction caused by a hernia Transmesosigmoid congenital in 1 adults. We discuss the clinical particularities of this rare form of internal hernia.

Closed bowel loop obstruction by a fibrous band mimicking paraduodenal hernia

Abstract Background A closed-loop obstruction occurs when a section of the intestine becomes blocked at two locations along its pathway, increasing the likelihood of volvulus and ischemia. Frequently, a single adhesive band is the primary cause of a closed loop, although internal hernias from congenital defects or iatrogenic intervention in the mesentery or omentum can also become other factors. In closed-loop obstruction, computed tomography (CT) often displays a distinctive pattern where the bowel appears dilated and filled with fluid, forming a ‘C-shaped’ configuration. Case presentation A 43-year-old female patient presented to the emergency department complaining of acute abdominal pain and repeated bilious vomiting with no history of absolute constipation. By examination, there were tenderness, guarding and rigidity. Her medical history includes type 1 diabetes since the age of 9 years and her surgical history included a onetime cesarean section and negative history of laparoscopic interventions. Ultrasound was done as a first-line investigation. It showed a few dilated bowel loops in addition to moderate intraperitoneal free fluid and could not detect the cause of bowel dilatation; therefore, non-contrast CT scan was requested and revealed the following findings: Two bowel loops exhibited distension and mucosal edema, and the configuration of bowel loops resembled a distinctive C-shape. Conclusion Distinguishing between adhesive small bowel obstruction (SBO) and paraduodenal hernia relies on clinical history, imaging features, and risk factors. Adhesive SBO often stems from prior surgery or inflammation and may exhibit ‘beak’ or ‘whorl’ signs on CT scans.

Internal Hernias: Diagnosis and Management

Introduction: Internal hernias are rare, with an overall incidence of less than 1%. They account for 0.5 to 5.8 % of cases of intestinal obstructions. If left untreated, their overall mortality exceeds 50 % in cases of strangulation. The aim of this work is to report 04 new cases of different types of internal hernias and to review the literature on the circumstances of occurrence, discovery, and therapeutic modalities for internal hernias. Observations: We report four (04) observations concerning different types of internal hernias: (02 peri-cecal internal hernias, one hernia through the Winslow's hiatus, and one supra-vesical internal hernia), all revealed by clinical presentations of acute intestinal obstructions and confirmed by preoperative CT scan. Our patients (03 men and 01 woman) have an average age of 63 years. All 04 cases were operated on urgently, with 03 undergoing laparotomy and 01 undergoing laparoscopy. The procedure performed is the reduction of the hernia (viable strangulated small bowel loops) with closure of the hernial orifice to prevent recurrences. Postoperative courses were uneventful in all four patients. The average length of hospital stay is 02 days. After a follow-up ranging from 02 years to 08 years, no recurrence was observed. Conclusion: Internal hernias are rare and should be considered in cases of acute intestinal obstruction, especially in patients without abdominal surgical history or trauma. Laparotomy remains the most commonly used surgical approach, but laparoscopy is increasingly reported in recent publications.

Bowel obstruction on internal hernia

Internal abdominal hernias are an uncommon etiology of intestinal obstruction. They are responsible for 0.2 to 5.8% of small bowel obstructions in published series1. Here, we report the case of a 27-year-old patient who presented to the emergency department with an occlusive syndrome. On examination, the abdomen was tympanically distended, and on imaging, the bowel was distended upstream of a thickening of the last ileal loop. The patient underwent emergency surgery, with exploration revealing an incarcerated bowel loop 40 cm from the ileocecal junction in the retrocecal fossa, indicative of an internal hernia with 4 cm of proximal bowel distension. The loop was successfully reduced and found to be viable.

Strangulated hernia of the foramen of Winslow complicated by acute colonic obstruction

Internal hernias, in particular, hernia of the foramen of Winslow, are rare and occur in typical sites. Laparotomy is common in these cases while laparoscopic surgery is rarely used in such urgent cases. However, modern diagnosis and treatment including computed tomography and laparoscopy allowing minimally invasive interventions are not an exception for patients with hernia of the foramen of Winslow. This approach is effective for this problem and prevents adverse outcomes of disease.

A rare case of Pouch of Douglas hernia- Atypical presentation in a postnatal mother

Background: Internal hernias are quite rare which constitutes right and left paraduodenal, trans-mesenteric hernia and pelvic hernias. Case presentation: 23 year old female postnatal mother delivered 4 months back, IUCD was inserted post delivery now presented with C/O greenish discharge PV and vaginal fullness. Ultrasound showed few dilated small bowel loops.Computed tomography revealed multiple dilated fluid filled small bowel loops suggestive of subacute small bowel obstruction. Herniation of the small bowel loops into the POD is noted.MRI revealed the small bowel loops in POD herniating through fornix into the vagina. Intraoperatively , small bowel loops were seen herniating through a defect in the POD on the right side into the fornix and formed a sac within the vagina. A sealed perforation was seen within the herniated loop and short segment gangrene was identified. Resection and anastomosis of bowel loop along with closure of defect in broad ligament defect was done. Conclusion: Pelvic hernia through the defect in cul-de-sac is very rare and high clinical suspicion is needed to diagnose this rare condition. Radiological knowledge of this rare entity in a patient with small bowel obstruction aids in early diagnosis and intervention avoiding the complications of bowel ischemia.

Case of laparoscopic treatment recurrent obturator hernia

Obturator hernia is an internal abdominal hernia in the pelvis, which is very rare in the practice of a surgeon. This hernia is more common in elderly women. The incidence varies but is approximately 0.05-0.07% of all hernias. Obturator hernias present a diagnostic challenge because signs and symptoms are often non-specific, making preoperative diagnosis difficult. They require high vigilance and caution in surgical treatment as many of these patients are elderly with the presence of comorbidities. Reports on the treatment modality, will benefit the surgical community regarding the management of obturator hernias. We present a rare case of recurrent obturator hernia causing recurrent small bowel obstruction in a 63- year-old woman.

Stranched Internal Hernia Revealed by Occlusion of the Large Libra: A Propos of a Case

Stranched Internal Hernia Revealed by Occlusion of the Large Libra: A Propos of a Case

Intestinal Obstruction due to an Internal Hernia in the Paracolic Gutter of the Descending Colon—A Case Report—

Intestinal Obstruction due to an Internal Hernia in the Paracolic Gutter of the Descending Colon—A Case Report—

A Case of Internal Hernia after Hepaticojejunostomy with Roux-en-Y Reconstruction

A Case of Internal Hernia after Hepaticojejunostomy with Roux-en-Y Reconstruction

Gastric bypass - 10 years' results.

Gastric bypass has not gained as much popularity in the Czech Republic as technically simpler restrictive bariatric procedures, frequently with a fading long-term effect. The aim of the presentation is to point out the long-term results after two types of gastric bypasses. Retrospective analysis of prospectively collected data in an initial set of patients after laparoscopic RYGB (Roux Y gastric bypass) and OAGB/MGB (one anastomosis/mini gastric bypass) performed at Breclav Hospital in 2010-2013. Evaluation based on the BAROS system, according to weight development, comorbidities, psychological aspects, complications and reoperations. Data available for evaluation are from 32 patients out of a total of 60; the follow-up rate is 53%. The patients are lighter by 34 kg on average (0-64 kg); TBWL (total basic weight loss): 25.7%. The majority of operated diabetics are free of signs of diabetes, and all others have a reduced need for antidiabetic medication. Hypertension, sleep apnea and psychological assessment of life in 6 domains improved. Eight of the 32 followed patients underwent reoperation during 10 years; only 2 of these procedures were acute for complications (anastomotic ulceration), both in smokers; further elective reoperations included 2 conversions of OAGB/MGB to RYGB due to reflux, 2 corrective surgeries, and 2 procedures for a suspected internal hernia. There was no conversion from laparoscopic to open surgery, no peritonitis associated with a leak, and no mortality within 30 days. The BAROS score (5.56) indicates a "very good result" of the gastric bypasses after 10 years. Gastric bypasses are safe and provide a high and lasting metabolic effect that meets the general expectations of an invasive intervention that can fundamentally improve the quality of treatment for otherwise incurable chronic diseases related to adiposity (so-called ABCD), especially type 2 diabetes.

Right paraduodenal hernia, classification, and selection of surgical methods: a case report and review of the literature

BackgroundConsidering that right paraduodenal hernia is a rare internal hernia with abnormal anatomy and is often encountered during an emergency, surgeons may lack knowledge about it and choose incorrect treatment. Thus, this case report is a helpful complement to the few previously reported cases of right paraduodenal hernia. Additionally, we reviewed all the reported right paraduodenal hernia cases and proposed appropriate surgical strategies according to different anatomical features.Case presentationThe case involved a 33-year-old Chinese male patient who was admitted to the hospital due to abdominal pain. The patient was initially diagnosed with small bowel obstruction, and conservative treatment failed. An emergency operation was arranged, during which a diagnosis of right paraduodenal hernia was made instead. After surgery, the patient recovered well without abdominal pain for 2 years.ConclusionAlthough right paraduodenal hernia accounts only for a small proportion of paraduodenal hernia, its anatomical characteristics can vary considerably. We divided right paraduodenal hernia into three types, with each type requiring a different surgical strategy.

Case Report: Strangulated Hernia on a Flange between Meckel's Diverticulum and the Appendix

Introduction: Meckel's diverticulum is a very common abnormality of the digestive tract, most often asymptomatic but revealed by a complication; Among these complications, occlusion, which has multiple mechanisms, one of the mechanisms is internal hernia. Case report we present the case of a young woman of 28 years old admitted to the emergency department for occlusion on an internal hernia strangulated through an abnormal orifice made of a flange between the appendix and a Meckel's diverticulum. the patient she was admitted urgently to the operating room. Treatment consisted of resection of the necrotic ileum including the meckel's diverticulum with an ileostomy, and an appendectomy. Peritoneal cavity lavage and drainage. the postoperative period was uneventful. The patient was discharged from the hospital on the fifth day after the operation. readmitted two months later for the restoration of intestinal continuity. Discussion: Internal hernias are rare, most of them remaining asymptomatic. Are responsible for bowel obstruction in 0.5 to 4.1% of cases. Meckel's diverticulum is the most common birth defect of the gastrointestinal tract. It most often remains asymptomatic, although, it can be revealed by a complication. complications can be haemorrhagic, obstructive, infectious, or tumorous. Mechanical occlusion is the most common complication in adults; it represents 24 to 53%. CT scan is the reference examination. Conclusion: Any abrupt-onset occlusive syndrome with dilated small loops in a central location in the abdominal cavity should, in a subject with no surgical history, raise the hypothesis of a strangulated internal hernia in principle.

Changing patterns and surgical outcomes of small bowel obstruction in the era of minimally invasive surgery for colorectal cancer.

This study aimed to investigate whether the incidence, patterns, and surgical outcomes of small bowel obstruction (SBO) have changed in the era of minimally invasive surgery (MIS) for primary colorectal cancer (CRC). Consecutive patients who underwent laparotomy for SBO were divided into MIS and traditional open surgery (TOS) groups based on the previous colorectal cancer operation technique used. The MIS group was selected from 1544 consecutive patients who underwent MIS as a treatment for primary CRCs between 2014 and 2022, while the TOS group was selected from 1604 consecutive patients who underwent TOS as a treatment for primary CRCs between 2004 and 2013. The demographics, clinicopathological features, and surgical outcomes were compared between the two groups. The SBO incidence in patients who underwent MIS for primary CRC was significantly lower than that in patients who underwent TOS (4.4%, n =68/1544 vs. 9.7%, n =156/1604, P <0.0001). Compared with the TOS group, the MIS group had significantly different ( P <0.0001) SBO patterns: adhesion (48.5 vs. 91.7%), internal herniation (23.5 vs. 2.6%), external herniation (11.8 vs. 1.9%), twisted bowel limbs (4.4 vs. 0.6%), ileal volvulus with pelvic floor adhesion (5.9 vs. 1.9%), and nonspecific external compression (5.9 vs. 1.3%). A subset analysis of patients with adhesive SBO (ASBO) showed that the MIS group tended to ( P <0.0001) have bands or simple adhesions (75.8%), whereas the TOS group predominantly had matted-type adhesions (59.4%). Furthermore, SBO in the MIS group had an acute (<3 months) or early (3-12 months) onset (64.7%), while that in the TOS group ( P <0.0001) had an intermediate or a late onset. When the surgical outcomes of SBO were evaluated, the TOS group had significantly more ( P <0.0001) blood loss and longer operation time; however, no significant difference was observed in the surgical morbidity/mortality (Clavien-Dindo classification ≧3, 11.8 vs. 14.1%, P =0.6367), hospitalization, and readmission rates between the two groups. Postoperative follow-up showed that the estimated 3-year (11.37 vs. 18.8%) and 6-year (25.54 vs. 67.4%) recurrence rates of SBO were significantly lower ( P =0.016) in the MIS group than in the TOS group. The wide adoption of MIS to treat primary CRC has led to a lower incidence, altered patterns, and reduced recurrence rates of SBO. Awareness of this new trend will help develop surgical techniques to prevent incomplete restoration of anatomical defects and bowel malalignments specifically associated with MIS for CRC, as well as facilitate timely and appropriate management of SBO complications whenever they occur.

IBC-Oxford University2023_BJSPoster_6Management of Gastrointestinal Obstruction due to Internal Hernia after Bariatric Metabolic Surgery

Abstract Background Gastrointestinal obstructions after bariatric metabolic surgery are uncommon. They could occur in the form of internal hernias, and port site hernia as we will present in this presentation. Objectives This work aims to introduce novel techniques for managing gastrointestinal obstructions after bariatric metabolic surgery. Methods This case-series study presents 3 cases with different types of gastrointestinal obstructions after bariatric surgery and the management plan. Results The postoperative results in 3 patients were uneventful, with excellent recovery. Conclusion All types of gastrointestinal obstructions which frequently occur in general surgery could also happen after bariatric surgery. So, we must respect patient complaints even if the investigations are not conclusive, and we have to respect also rare cases of obstruction related to bariatric surgery.

IBC-Oxford University2023_BJSPoster_14Short-Term Outcomes of Single-Anastomosis Sleeve-Ileal Bypass (SASI)

Abstract Background The SASI bypass, which is a simplified version of sleeve gastrectomy with transit bipartition, is based on the same metabolic principles, particularly the early postprandial ileal brake. Compared to SASI bypass, sleeve gastrectomy offers advantages such as shorter operation time and lower incidence of internal herniation. The aim of this study was to assess the safety and outcomes of SASI bypass over a 3-year follow-up period. Methods A retrospective study was conducted on all patients who underwent SASI bypass between January 2018 and June 2023. The primary endpoints were weight loss and diabetic remission. Results A total of 54 patients, with a mean age of 39,4 ± 15 years and a mean body mass index of 38,5 ± 6,8 kg/m2, underwent SASI bypass. There was no significant early postoperative complications. At the end of the first year, the average percentage of excess weight loss (%EWL) was 82,6 ± 7,4, and the rate of diabetic remission was 96,1 %. After 3 years, the %EWL was 97,4 ± 4,1, and the diabetic remission rate was 98,8%. Severe protein-energy malnutrition occurred in 4 patients(7,4%), and reversal of the bypass were made in 3 of 4 patients. Technical variations did not significantly affect %EWL or diabetic remission. Conclusion SASI bypass demonstrated promising outcomes in terms of 3-year %EWL and diabetic remission. While the double-outlet for gastric content allows access to the duodenum, it may hinder the standardization of postoperative care. Furthermore, the presence of a double-outlet does not guarantee the absence of malnutrition.

Lessons learnt in the management of paraduodenal hernias: a case series.

Paraduodenal hernias (PDH) are rare congenital internal hernias with non- specific symptoms. Left-sided paraduodenal hernia is three times more common than right-sided paraduodenal hernia with similar clinical presentation but different embryological origins. We report a series of eight cases of paraduodenal hernia who presented with varied clinical presentation ranging from vague abdominal pain to complete intestinal obstruction. Six cases had left-sided paraduodenal hernia, while two cases had right-sided paraduodenal hernia. Seven cases based on their presentation underwent surgery either electively or on emergent basis. Three cases underwent laparoscopic repair. One case had a recurrence and was re-operated four months later. There was no mortality among any of the cases. A pre-operative diagnosis of paraduodenal hernia is essential. Laparoscopic surgery is safe in select cases and is found to be beneficial.

EGS P23 A rare case of gallstone ileus post Roux-en-Y Gastric Bypass: Stone migration from large duodenal diverticulum

Abstract Background Small bowel obstruction following Roux-en-Y gastric bypass is common and is mainly attributed to adhesions or internal herniation. Intraluminal formation of stones, usually in areas of stasis due to the anatomical changes post-RYGB, and migration to the distal ileum to cause acute bowel obstruction is rare. Impacted stones at the duodenal diverticulum can trigger diverticular inflammation, back pressure to the common bile duct and pancreas resulting in abdominal pain, nausea and vomiting, intermittent derangement of liver enzymes and episodes of cholangitis and pancreatitis. The impaction at the distal ileum is an emergency requiring prompt diagnosis and intervention to prevent complications. Methods This is a case report of a 56-year-old female who presented at East Surrey Hospital in February 2023 with recurrent upper abdominal pain, nausea and vomiting. She previously underwent an open cholecystectomy for cholelithiasis and cholecystoduodenal fistula (2003) and a Roux-en-Y gastric bypass (2018). Her symptoms were initially thought to be secondary to inflammation and periduodenal abscess managed with antibiotics, but as time and scans (CT, MRCP, water-soluble contrast, gastroscopy) progressed without resolution of her symptoms it became evident that she had developed mechanical bowel obstruction. We described her case and the diagnostic challenges leading to the final surgical management. Results To investigate the patient’s symptoms, her intermittently raised inflammatory markers, deranged liver enzymes and amylase a series of radiological examinations was rperformed. Initial CT scan showed an inflamed large duodenal (D3) diverticulum and fluid filled proximal duodenum. Subsequent MRCP demonstrated dilated common bile duct and intrahepatic ducts without any ductal stone. Repeat CT scan two weeks later, confirmed small bowel obstruction due to a heterogenous bolus at the ileocecal valve with resolution of the duodenal inflammation and dilatation. The patient underwent a laparoscopic extraction of a stone impacted at the ileocecal valve causing small bowel obstruction and recovered well. Conclusions Even though small bowel obstruction due to stone aggregation is uncommon post-RYGB, a high index of suspicion for the diagnosis and a low threshold for early laparoscopic intervention can prevent further serious complications. Reporting these cases in literature offers a guidance for the workup and management of these unusual scenarios amongst surgical teams and improves patients’ outcomes.

Ultrasound as the first line investigation for midgut malrotation: a UK tertiary centre experience

To present the first 22-months experience of transitioning to an ultrasound-first pathway for suspected midgut malrotation. An "ultrasound-first" imaging pathway was initiated in October 2021. Twenty-two-months later, a search was undertaken of all <1-year-old patients with "bilious", "malrotation," or "volvulus" as the imaging indication. Reports and images from upper gastrointestinal fluoroscopy (UGI) and ultrasound were reviewed, and diagnoses and outcomes were documented. The search yielded 101 eligible cases between October 2021 and July 2023. Of the patients, 63/101 (62%) had both ultrasound and UGI: 47/63 (75%) ultrasound first, 16/63 (25%) UGI first. Thirty-one per cent (31/101) had ultrasound only and 7/70 (10%) UGI only. The pathway diagnosed 7/8 (88%) infants with midgut malrotation with or without volvulus and one infant who had an inconclusive ultrasound examination with a suspected an internal hernia and who was found to have malrotation volvulus at surgery. Twenty-one infants who had confidently normal ultrasound examinations and who also had UGI all had a normal duodenojejunal flexure position. Ultrasound detected alternative pathology in eight children. Duodenal visualisation improved with time: 6/15 (40%) in the first 6 months to 23/34 (68%) after the first year. The transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively in a UK centre, which previously relied solely on UGI.

Acute Intestinal Occlusion: Think About Supra Bladder Internal Hernia

Internal hernia of the supravesical fossa is a rare cause of intestinal obstruction [1]. This pathology arouses great interest among radiologists and surgeons due to its diagnostic difficulty, even with the advancement of different imaging techniques, particularly computed tomography [2]. We present the case of a patient without a history of laparotomy who presented with acute intestinal obstruction. Computed tomography examination revealed a strangulated left supravesical internal hernia. Diagnostic confirmation was obtained by laparoscopic exploration.