Intestinal malrotation is a rare congenital anomaly that typically presents during infancy; adult presentations are uncommon and often manifest with vague, chronic gastrointestinal (GI) symptoms. We report a unique case of a woman in her 30s who presented with acute bilious vomiting, severe malnutrition and a 2-year history of post-prandial vomiting and weight loss. Imaging revealed high-grade distal duodenal obstruction, mesenteric swirling and an absent right colon. Laparoscopic exploration demonstrated Ladd's band duodenal obstruction, pre-superior mesenteric artery (SMA) malrotation or non-rotation with concomitant post-SMA reverse rotation and a separate bowel segment involved in a chronic midgut volvulus through an internal hernia defect - a combination not previously described. A laparoscopic Ladd's procedure with internal hernia reduction was carried out. Laparoscopic management of complex cases of intestinal malrotation is feasible. Clinicians should maintain a high index of suspicion for congenital anomalies in adults who present with duodenal obstruction or recurrent, unexplained GI symptoms.

Decompressive Craniectomy: Surgical Techniques and Complication Avoidance.

Optimizing the diagnostic strategy for accurate detection of internal herniation following Roux-en-Y gastric bypass: a diagnostic accuracy study

A 55-year-old woman presented with vomiting and abdominal pain. Physical examination revealed abdominal tenderness, but no rebound tenderness. A computed tomography (CT) scan revealed a distended small intestine called the flower bouquet sign, as well as the fat notch sign. These findings supported the suspicion of adhesive small bowel obstruction (SBO). Emergency surgery confirmed the presence of an adhesive band formed and it was resected. The patient recovered uneventfully. Most cases of SBO are caused by adhesions, followed by internal hernias and volvulus. CT scanning is essential for diagnosing adhesive SBO, which exhibits characteristic signs such as the beak sign, fat notch sign, small bowel feces sign, and flower bouquet sign. The flower bouquet sign refers to the distended small bowel segments arranged radially within a closed loop, resembling flowers and stretched mesenteric vessels that converge toward the transition zone, resembling stems. The fat notch sign indicates extraluminal compression of the bowel by an adhesive band at the transition zone. This case underscores the importance of recognizing adhesive SBO early on through characteristic imaging signs to mitigate the risk of life-threatening complications, such as ischemia or perforation.

Encapsulating peritoneal sclerosis: a three-case series highlighting diagnostic challenges and surgical managements

Sleeve gastrectomy (SG) is widely performed, yet 20-50% of patients experience insufficient weight loss or weight regain, leading to revisional surgery. Roux-en-Y gastric bypass (RYGB) and single-anastomosis duodeno-ileal bypass (SADI-S) are two commonly used revisional procedures, but long-term comparative data remain limited. This study evaluates 7-year outcomes of RYGB versus SADI-S as revisional surgeries for weight recurrence after SG. A retrospective analysis was conducted on all adults undergoing revisional RYGB or SADI-S between 2014 and 2015 after inadequate weight loss or weight recurrence post-SG. Demographic, anthropometric, biochemical, and comorbidity-related variables were assessed at baseline, 1, 5, and 7years. Statistical analyses included t-tests, chi-square tests, Kaplan-Meier curves, and multivariate regression (significance set at p < 0.05). The cohort included 105 patients (RYGB = 62; SADI-S = 43). SADI-S patients had higher baseline and pre-revision BMI. Across all follow-up points, SADI-S achieved significantly greater %TWL, %EWL, and BMI reduction, demonstrating superior long-term weight-loss durability. RYGB yielded markedly better GERD resolution (95 vs. 5%, p = 0.02), while remission of diabetes, hypertension, dyslipidemia, and asthma was similar between groups. Nutritional profiles differed: SADI-S was associated with lower calcium, zinc, folate, and vitamin D levels, whereas RYGB patients had lower vitamin B12. Overall complication rates, including bleeding, marginal ulcer, internal hernia, dumping syndrome, severe malnutrition, and iron-deficiency anemia, were not statistically significant. Both RYGB and SADI-S are effective and safe revisional options after SG. SADI-S offers superior long-term weight-loss and metabolic outcomes, whereas RYGB remains preferable for patients with significant or persistent GERD. Tailoring revisional procedure selection to patient characteristics and ensuring lifelong nutritional monitoring are essential for optimizing long-term outcomes.

BACKGROUND Internal hernias through the pars flaccida of the lesser omentum are rare variants that pose unique diagnostic and therapeutic challenges, representing less than 1% of all internal hernias. Diagnosis is particularly challenging due to their nonspecific presentation and subtle radiological features. CASE REPORT We present a case of successful laparoscopic repair of a pars flaccida internal hernia in a 52-year-old woman with complex surgical history, including previous colorectal cancer surgery. We detail our systematic surgical approach and conducted a comprehensive literature review of laparoscopically managed pars flaccida hernias using the PubMed database. The patient presented with recurrent episodes of epigastric pain and nausea. Diagnostic laparoscopy revealed herniation of the small bowel through the pars flaccida anterior to the stomach, along with a secondary mesenteric defect. Both defects were successfully repaired laparoscopically using non-absorbable sutures. Key technical elements included strategic 5-port placement, systematic adhesiolysis, and meticulous reduction of the herniated bowel. The patient's symptoms resolved after repair. CONCLUSIONS Laparoscopic repair of pars flaccida hernias is feasible with appropriate technical expertise. Success depends on careful preoperative planning, strategic port placement, and thorough inspection for additional defects. This case highlights the importance of considering internal hernias in patients with intermittent abdominal pain following previous surgery, even when initial imaging is inconclusive.

Obesity is a complex chronic disease with a rising global prevalence and significant health implications. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely performed bariatric procedures worldwide, ensuring significant weight loss and reducing obesity-related comorbidities. However, the risk of postoperative complications remains considerable. Multidetector computed tomography (MDCT) is regarded as the primary imaging modality for the assessment of suspected complications, due to its high diagnostic accuracy. This review offers a comprehensive overview of early (≤ 30 days) and late (> 30 days) postoperative complications, including anastomotic leak, abscess, hemorrhage, small bowel obstruction (SBO), internal hernia, gastro-gastric fistula, intussusception, and marginal ulcer, with emphasis on characteristic MDCT features. Due to its advantage as a dynamic method, upper gastrointestinal (Gl) studies with oral contrast material may be helpful for the diagnosis of leak and gastro-gastric fistula formation. A comprehensive understanding of the altered postoperative anatomy and the specific radiological signs of complications are essential for accurate MDCT interpretation, minimizing diagnostic errors and enabling timely, targeted clinical intervention. Today, MRI can be considered a problem-solver through its possibility of combining static with dynamic sequences in selected cases. In this narrative review, we highlight the most frequent complications of Roux-en-Y gastric bypass (LRYGB), allowing radiologists to become familiar with the typical radiological features and pitfalls in MDCT, upper GI studies, and MRI, when facing this type of surgery. CRITICAL RELEVANCE STATEMENT: Postoperative complications following laparoscopic LRYGB can pose considerable diagnostic challenges. Although MDCT is the most important modality, upper GI studies (for leakage or suspected gastro-gastric fistula) and increasingly MRI (for pouch problems or in pregnant patients) can improve diagnostic accuracy and support effective clinical decision-making. KEY POINTS: LRYGB complications are challenging due to altered anatomy and distinct imaging features. Postoperative bleeding, leaks with/without abscess, small bowel obstruction, and internal hernia are the most common serious complications. MDCT evaluation and reporting should be structured and focus on characteristic CT signs to support accurate imaging diagnosis.

Gastric cancer continues to pose a significant global health burden, with gastrectomy being the primary curative treatment. However, the increased performing of laparoscopic gastrectomy (LG) has been associated with a rising incidence of postoperative internal hernia (IH), particularly Petersen's hernia (pH), which may lead to bowel strangulation and necrosis. This meta-analysis aimed to compare the incidence of IH following LG versus open gastrectomy (OG) and to evaluate the preventive effect of Petersen's space closure on pH occurrence. A systematic review and meta-analysis were conducted using PubMed and Embase to identify studies published in the past 25years that reported IH or pH after gastrectomy for gastric cancer. Eligible studies compared (1) the incidence of IH between LG and OG or (2) the incidence of pH between closure and nonclosure of Petersen's space. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Five studies comparing LG and OG demonstrated a significantly higher risk of IH in the LG group (OR 2.81, 95% CI: 1.40-5.62). A subgroup analysis limited to total gastrectomy showed a nonsignificant trend toward increased IH risk after LG (OR 6.12). Additionally, five studies showed that closure of Petersen's space significantly reduced the risk of pH (OR 5.73, 95% CI: 1.59-20.67). Laparoscopic gastrectomy is associated with an increased risk of internal hernia compared to open surgery for gastric cancer. The preventive closure of Petersen's space should be considered mandatory, particularly during Roux-en-Y reconstruction after gastrectomy.

We present the case of a 19-year-old male with Gardner syndrome, status post total proctocolectomy and ileal pouch-anal anastomosis (IPAA) at 8 years of age, who developed an internal hernia and volvulus more than 10 years following ileostomy reversal. Patients with a history of total proctocolectomy and IPAA are at an increased risk for long-term complications such as internal hernias and volvulus due to altered anatomy and mesenteric defects. Early imaging and prompt surgical intervention were crucial in preventing ischemia of the J-pouch and the possible need for a permanent ileostomy in our teenaged patient. This case describes a medical condition that has not been well characterized in the literature and emphasizes the importance of prolonged clinical vigilance and surveillance in post-IPAA patients, as mild symptoms may signal serious complications requiring urgent intervention, even many years after ileostomy reversal.

Retrocecal internal hernia causing an acute bowel obstruction

Early and late complications after laparoscopic Roux-en-Y gastric bypass and sleeve gastrectomy: a nationwide propensity-score matched study.

A female in her late 20s presented to the emergency department with 1 day of right lower quadrant pain, nausea and emesis. Imaging demonstrated an exophytic right ovarian cyst in addition to small bowel in the pelvis with faecalisation and fat stranding. The patient was taken emergently to the operating room for a joint procedure with the gynaecology team, consisting of a diagnostic laparoscopy and cystectomy. In the operating room, she was found to have small bowel incarcerated within a defect in the pouch of Douglas. This is a rare case in which a small bowel obstruction was caused by an internal hernia within the pouch of Douglas.

Internal herniation through a defect in the falciform ligament of the liver is an exceptionally rare occurrence with a risk of small-bowel obstruction that can result in strangulation and bowel necrosis if diagnosis is delayed. Because of its infrequency, available evidence is limited to isolated case reports and small descriptive studies, and optimal diagnostic and operative strategies remain poorly defined. A systematic search of PubMed/MEDLINE, Embaseand Cochrane Library was performed to identify English-language articles published over the past 10 years reporting cases of internal herniation through the falciform ligament. Titles and abstracts were screened using predefined inclusion and exclusion criteria, followed by full-text review. Data were extracted regarding patient demographics, presentation, imaging findings, operative managementand outcomes. A qualitative synthesis was undertaken in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Seven studies met the inclusion criteria, all of which were single-patient case reports or imaging-focused descriptions. Patients typically presentations varied but included acute abdominal pain and symptoms of small-bowel obstruction, and both congenital and iatrogenic falciform ligament defects were implicated. Computed tomography frequently demonstrated closed-loop bowel positioned anterior to the liver, beak-like tapering at the site of constrictionand abnormal displacement of the round ligament. All patients underwent urgent surgical intervention. Management consisted of reduction of the herniated viscus with division or closure of the falciform ligament defect, with bowel resection required when ischemia was present. Both open and laparoscopic approaches were reported, and short-term postoperative outcomes were generally favourable. Internal herniation through the falciform ligament is a rare but potentially serious surgical emergency that should be considered in cases of unexplained proximal small-bowel obstruction. Recognition of characteristic computed tomography findings may facilitate earlier diagnosis and intervention. Prompt operative exploration remains the cornerstone of management, with ligament division or closure and selective bowel resection based on intraoperative viability.

Obesity is a major health concern, affecting over 1 in 8 people worldwide. Bariatric surgery (BS) is currently the most effective long-term treatment for morbid obesity. In addition to sustained weight loss, BS is beneficial in treating obesity related comorbidities including dyslipidemia and type2 diabetes (T2DM). The beneficial effects of BS are a result of weight loss and surgery-induced shifts in the gut microbiota and its metabolites. At the same time, BS may also lead to complications and side effects. Abdominal pain is one of the most frequently reported complaints after BS with a prevalence of 33.8-54.4% within this patient group. However, in many patients the abdominal pain remains unexplained beyond gallstones, internal herniation, and ulcers. This raises the question whether the gut microbiota itself may play a direct role in the pathophysiology of unexplained abdominal pain. Over the years several studies have shown changes in the gut microbiota and related metabolites after BS. These include increased gut microbial diversity and altered microbial composition after BS. Higher abundances of Proteobacteria and Fusobacteria are reported, while a decrease in butyrate-producing Firmicutes is reported. Along with these changes in microbiota, BS causes higher plasma bile acid levels and altered short-chain fatty acid (SCFA) profiles. These metabolic shifts are believed to support weight control, glucose regulation, and lipid metabolism. More recently, specific microbial taxa and metabolite profiles were linked to abdominal complaints following BS. This suggests that dysbiosis and metabolites may play a role in unexplained abdominal pain after BS.

Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract and is usually asymptomatic, making preoperative diagnosis difficult in children. We report a 6-year-old boy with a 4-5-day history of progressively worsening periumbilical abdominal pain accompanied by non-bilious vomiting and acute obstipation, with no passage of stool or flatus by the time of presentation. On admission, he appeared ill with abdominal distension, focal periumbilical tenderness, rebound, and involuntary guarding. Laboratory studies did not reveal significant abnormalities. Erect and supine abdominal x-ray showed multiple air-fluid levels, and ultrasound revealed markedly dilated small-bowel loops with collapsed colonic segments, consistent with a high-grade mechanical obstruction. Urgent exploratory laparotomy identified Meckel’s diverticulum with a non-patent tip that was tethered to the umbilicus by a narrow fibrotic omphalomesenteric band; several ileal loops were entrapped beneath this band, producing complete obstruction without volvulus or ischemia. The band was divided, controlled decompression through the diverticular tip was performed, and wedge resection of the diverticulum with transverse ileal closure was completed. The patient resumed oral intake on postoperative day 3 and was discharged in good condition on day 6. This case highlights internal herniation beneath an omphalomesenteric band as an important but easily overlooked mechanism of small-bowel obstruction in children. Early recognition of this mechanism and timely operative exploration are essential to prevent delays in definitive management.

Patient: Female, 33-year-oldFinal Diagnosis: Internal herniaSymptoms: Abdominal pain nausea vomitingClinical Procedure: —Specialty: Anatomy • Gastroenterology and HepatologyObjective: Rare diseaseBackgroundParaduodenal hernia (PDH) is a rare internal hernia, accounting for 50% to 55% of internal hernias but only 0.2% to 0.9% of intestinal obstructions. Right-sided PDH is less common, occurring in approximately 25% of cases.Case ReportThis case describes a 33-year-old pregnant woman at 20 weeks 6 days gestation who was admitted with a 15-day history of abdominal distension accompanied by nausea and vomiting. The patient had postprandial exacerbation of intermittent abdominal pain, bilious vomiting, and significant weight loss (5 kg), with a history of similar symptoms during previous pregnancies. Abdominal contrast-enhanced computed tomography revealed clustered bowel loops in the right upper quadrant and medial displacement of the superior mesenteric vein, which is consistent with right-sided PDH complicated by intestinal malrotation. After conservative treatment failed, the patient opted for pregnancy termination followed by laparoscopic surgery. Intraoperative exploration confirmed complete absence of fusion between the ascending mesocolon and the posterior peritoneum, resulting in a wide hernia defect through which bowel loops had herniated into the space lateral to the ascending duodenum. The procedure included reduction of herniated contents, adhesiolysis, and fixation of the ascending mesocolon. The patient’s recovery was uneventful, and she was discharged on postoperative day 5. At 3-month follow-up, no abnormalities were noted.ConclusionsGiven its nonspecific clinical presentation, PDH is frequently misdiagnosed or diagnosed late. Abdominal computed tomography facilitates early diagnosis and timely intervention, while laparoscopic repair offers favorable outcomes.

Total pancreatectomy and islet autotransplantation (TPIAT) is a complex surgical procedure performed in transplant centers throughout the United States, with increasing prevalence over the last 2 decades. The goals of TPIAT are to alleviate pain caused by debilitating chronic pancreatitis or acute recurrent pancreatitis by removing the pancreas and to prevent the development of brittle diabetes by infusion of pancreatic islet cells to replace the function of the surgically absent pancreas. Imaging plays a key role in evaluating patients who have undergone TPIAT. Radiologists must be aware of the surgical procedure and its variations, expected postoperative imaging findings, and potential complications for accurate diagnosis. The authors review the background of TPIAT and the indications for and goals of the procedure. The surgical procedure, expected postsurgical anatomy, imaging findings, and spectrum of complications are described. Imaging findings of postoperative complications and sequelae of TPIAT may include bowel or bile leak, anastomotic breakdown, abscess, hematoma, biliary stricture, bowel obstruction due to anastomotic stricture, adhesions, incisional or internal hernia, delayed gastric emptying, bezoar, vascular abnormalities (eg, thrombosis, pseudoaneurysm), omental infarct and/or asymptomatic fat necrosis, and atypical patterns of hepatic steatosis, including nodular hepatic steatosis. ©RSNA, 2026.

Acute abdomen is a common indication to surgery in paediatric emergency departments. Appendicitis is the most frequent diagnosis, followed by bowel obstruction and female genital conditions. Some rare aetiologies may lead to challenges in surgical management. Aim of this study is to analyse the distribution of rare causes of acute abdomen in patients undergoing emergency surgery in the past five years at our centre. Records of patients undergone urgent abdominal surgery were retrospectively reviewed from 2015 to 2019. Information relative to age, sex, underlying pathology, and surgery was recorded. The inclusion criteria were age <18 years and undergoing abdominal surgery. Neonates were excluded. The study population consisted of 957 patients. Median age was 9.7 years. Surgical procedure was laparoscopic in 22%, open in 78%. Common diagnoses were appendicitis in 815 patients, bowel obstruction in 72, adnexal and gynaecological pathology in 43, trauma in 9, complicated Meckel's diverticulum in 8. Rare findings included omental pathology (2), endometriosis (2), ectopic pregnancy (1), intestinal duplication (1), internal hernia (1), Amyand's hernia (1), epiploic appendix torsion (1), accessory spleen torsion (1). The aetiologies of acute abdomen in children vary depending on the age. Appendicitis is the most common surgical cause of acute abdomen, followed by other causes. Differential diagnosis, including rare pathologies, is required to predict the right surgical approach and to apply the proper treatment. Imaging techniques sometimes still result too invasive or insufficient, whereas the widespread use of laparoscopy may render surgical exploration acceptable in selected cases.

Internal hernias are rare causes of acute abdominal pain and can lead to severe intestinal obstruction. We report the case of a 38-year-old female patient presenting with abdominal pain localised in the left iliac fossa (FIG) and suprapubic region, with tenderness on palpation, partially relieved by morphine. Abdominal and pelvic computed tomography (CT) with and without contrast injection ruled out renal colic and led to a diagnosis of left paraduodenal internal hernia with upstream duodenal distension. No signs of acute complications were observed.