Internal Hernia Research Articles

Quality of stapled mesenteric defect closure influences the chance of reopening after laparoscopic Roux-en-Y gastric bypass surgery

Internal herniation (IH) is a common problem after laparoscopic Roux-en-Y gastric bypass surgery (RYGB). Routine closure of the mesenteric defects (MDs) reduces the risk of IH. Only very few articles report on risk factors for IH or describe detailed closing techniques. There is no consensus yet on the best closing method. The objective of this study is to determine the optimal stapling method for closure of MDs after RYGB. All performed RYGB procedures in our high-volume bariatric institute were included. Quality of the closure was scored in the categories poor, sub-optimal, and optimal, to see if the quality of the closure would predict the chance of reopening of the MDs and, therefore, the chance of IH. During any type of laparoscopy in the follow-up of the patient, the conditions of the MDs were stated, for example during diagnostic laparoscopy in symptomatic patients suspicious for IH or during laparoscopic cholecystectomy. Technically well-executed closure of Petersen’s space (PS) with two rows of staples had a greater chance of still being closed upon re-inspection compared to closure with one row (odds ratio = 8.1; 95% confidence interval [1.2–53.2], p = 0.029). Optimal closure of the MD at the jejuno-jejunostomy (JJ-space, JJS) resulted in more closed JJSs upon re-inspection compared to sub-optimal closure (odds ratio = 3.6 [CI 95% 0.8–16.1], p = 0.099). Non-optimally closed MDs had higher reopening rates and, therefore, pose an additional risk for IH. Our classification provides a quality assessment of MD closure during RYGB and gives insight into how to optimize surgical technique.

Mesentery-Sparing Technique: a New Intracorporeal Approach for Urinary Diversion in Robot-Assisted Radical Cystectomy.

Robotic-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is associated with significant morbidity and mortality. We present an alternative technique that preserves the complete mesenteric vascularization during the isolation of the intestinal segment used in ICUD, including distal vessels. This approach aims to minimize the risk of ischemia in both the ileal anastomosis and the isolated loop at the diversion site. This cohort study included 31 patients, both male and female, who underwent RARC with ICUD from February 2018 to November 2023, performed by a single surgeon. Intraoperative and postoperative complications data were retrieved for analysis, employing our proposed mesentery-sparing technique in all cases. The primary endpoint was the incidence of intraoperative and postoperative complications directly attributable to the mesentery-sparing approach in ICUD. Secondary endpoints included other postoperative variables not directly related to mesentery preservation, such as the incidence of postoperative ileus requiring parenteral nutrition and the duration of hospitalization. None of the patients experienced intraoperative or postoperative complications directly related to mesentery-sparing, such as intestinal fistulae or internal hernias. The median duration of hospitalization was 6 days, and postoperative ileus necessitating total parenteral nutrition occurred in 19% of the patients. Minor complications (Clavien-Dindo grades I-II) accounted for 27.6% of the cases and major complications (grades III-V) accounted for 20.6%. The mesentery-sparing technique outlined herein offers an alternative method for preserving the vascularization of intestinal segments and reducing the risk of intestinal complications in ICUD during RARC.

Increased Attenuation of Intestinal Contents at CT Indicates Bowel Necrosis in Closed-Loop Small Bowel Obstruction.

Background Preoperative recognition of irreversible bowel necrosis is important, as it provides valuable guidance for surgical strategy selection but also may inform perioperative risk assessment and communication. Few studies have focused on the association between CT signs and bowel necrosis. Purpose To assess the diagnostic accuracy of CT signs to predict bowel necrosis in patients with closed-loop small bowel obstruction (CL-SBO). Materials and Methods This retrospective single-center study included patients who were surgically confirmed to have CL-SBO caused by adhesion or internal hernia between January 2016 and May 2022. Necrosis was determined based on surgical exploration and postoperative pathologic examination. Two radiologists independently reviewed CT signs by both subjective visual assessment and objective measurement. Disagreements were resolved in consensus with a third gastrointestinal radiologist. Univariable and multivariable analyses were used to assess the association between CT signs and bowel necrosis, and Cohen κ was used to assess interobserver agreement. Sensitivity and specificity were calculated for each CT sign. Results This study included 145 patients: 61 (42.1%) in the necrotic group (median age, 62 years [IQR, 51-71.5 years]; 37 [60.7%] women) and 84 (57.9%) in the nonnecrotic group (median age, 61.5 years [IQR, 51-68.8 years]; 51 [60.7%] women). Univariable analysis and multivariable analysis showed that increased attenuation of intestinal contents and increased attenuation of intestinal wall were independent predictors for bowel necrosis (odds ratio = 45.3 and 15.1; P = .001 and P < .001, respectively). Increased attenuation of intestinal contents and increased attenuation of intestinal wall had similar sensitivity (64% and 67%, respectively) and specificity (99% and 92%, respectively) for predicting bowel necrosis. However, interobserver agreement was better for assessing the contents than the wall (κ = 0.84 and 0.59, respectively). Conclusion Increased attenuation of intestinal contents was a highly specific CT sign with good reproducibility to predict bowel necrosis in CL-SBO. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Taourel and Zins in this issue.

Internal hernia secondary to Fitz-Hugh-Curtis syndrome causing small bowel obstruction

We present a 56-year-old female who presented with symptoms suggestive of a small bowel obstruction (SBO) in a virgin abdomen. Cross-sectional imaging and laparoscopy revealed an internal hernia through perihepatic adhesions that are likely representative of Fitz-Hugh-Curtis syndrome (FHCS). These adhesions were divided, the small bowel reduced, and she made an unremarkable recovery. This is the first reported case of an internal hernia from FHCS causing an SBO.

Predictors of Length of Hospital Stay After Reduction of Internal Hernia in Patients With a History of Roux-en-Y Gastric Bypass.

Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited. This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS. We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43months. Petersen's defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen's and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2days. On the multivariate analysis, male sex (P = .019), conversion to exploratory laparotomy (P = .005), and resection of small bowel (P < .001) were independent risk factors for increased LOS. The most common location of IH after RYGB is Petersen's defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel.

Uncommon presentation of complicated internal hernia through the appendices epiploicae ring of adhesion: a clinical case study.

Internal hernias are infrequent, yet serious, medical conditions with potentially severe consequences. An internal hernia resulting from an Appendices epiploicae (AE) ring is an especially rare cause, with a mere nine documented instances worldwide. This report presents the case of a 58-year-old male who suffered from an internal hernia originating from an AE ring. The condition led to a gangrenous small bowel, which was treated by laparotomy and resection of the affected segment, followed by primary anastomosis. The post-operative recovery was favorable. Internal hernias, although rare, warrant immediate attention and early intervention to preclude detrimental outcomes, as illustrated in this particular case.

Wandering Spleen in Operated Case of Congenital Diaphragmatic Hernia

Wandering spleen (WS) is a rare condition characterized by abnormal mobility of the spleen due to laxity or absence of its supporting ligaments. We report an exceptional case of WS in a pediatric patient who had previously undergone surgical repair for congenital diaphragmatic hernia (CDH). A 16-year-old male, with a history of CDH repair in infancy, presented with a two-day history of abdominal pain and vomiting. Clinical examination revealed abdominal distension, tenderness, and sluggish bowel sounds. Imaging studies, including a contrast-enhanced computed tomography (CECT) scan, indicated small bowel obstruction due to an internal hernia, potentially involving the foramen of Winslow. Intriguingly, the patient's spleen had migrated to the left iliac fossa, accompanied by partial thrombosis of the splenic vein. Surgical intervention was deemed necessary. During exploratory laparotomy, the patient was found to have a reversed anatomy, with the ascending colon, cecum, and appendix on the left side, and the small bowel on the right side. Additionally, a WS was discovered with a long and tortuous splenic vein and artery. Surgical procedures included adhesiolysis, primary closure of serosal tears, splenopexy for spleen repositioning, and bowel derotation. The patient's postoperative recovery was uneventful, and he was monitored closely to ensure the resolution of the complications associated with this unique presentation.

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.