Internal hernia

all about internal hernias

1. Internal hernia PRESENTER: Dr,INDUMATHI.B MODERATOR:Dr.B.G . MANJUNATH Dr.JAGADISH S GANAGI

2. Internal hernia is defined as protrusion of viscus ,through an intra-abdominal aperture with out traversing fascial planes. Internal herniation occur when a portion of the small intestine becomes entrapped in one of the retroperitoneal fossae or in a congenital mesenteric defect. It is responsible for 0.6 to 5.8% of small bowel obstruction. Acute or congenital is often associated with symptoms of small bowel obstruction. Mortality associated with internal hernia is high as 31-50%,it is over estimated because of increase use of Roux-en-y gastric bypass to treat morbid obesity has heightened awareness of this condition.

3. Surgical anatomy DUODENUM 25Cm long, C-shaped bend which embraces the head of the pancreas. 1 st part-extends up, backwards and to the right of the level of upper border of first lumbar vertebra.5cm long. 2 nd part- extends downwards to the level of the lower border of the 3rd lumbar vertebra,7.5cm long. 3 rd part-extends to the left and then upwards to the level of the left side of the 2 nd lumbar vertebra,12.5cm long.

4. peritoneum The peritoneum is a thin ,translucent ,serous membrane, and it is the largest and most complexly arranged serous membrane in the body. The peritoneum that lines the abdominal wall is called parietal peritoneum. The peritoneum that covers the viscera is called visceral peritoneum. Both types of peritoneum has single layer of simple cuboidal epithelium called mesothelium. A capillary serous fluid separates the parietal and visceral layers of peritoneum from one surface and lubricates the peritoneal surfaces. The peritoneal cavity is a potential space between the parietal peritoneum and the visceral peritoneum.

5. In men ,the peritoneal cavity is closed, but in women it communicates with extra peritoneal pelvis exteriorly through fallopian tube, uterus and vagina . Peritoneal ligaments, mesentery and omentum divide the peritoneum into two compartments, the greater sac, and a diverticulum, omental bursa, or lesser sac. Peritoneal ligaments are double layered or folds of peritoneum that support a structure within the peritoneal cavity. Omentum is a mesentery or double layer of peritoneum that extends from the stomach and duodenal bulb to adjacent organs. The lesser omentum is made up of gastrohepatic and hepatoduodenal ligaments, attaches the stomach and duodenal bulb to liver. The greater omentum is attached to the stomach and hangs like an apron from the transverse colon.

6. Embrylology of peritoneum The abdominal cavity provides a room for the viscera to grow and shift in position. The primitive gut forms within the abdominal cavity and is suspended by a plane composed of two peritoneal reflections called the primitive mesenteries. The position of gut within the primitive symmetry plane divides primitive mesentry into ventral and dorsal portions. Vascular and lymphatic vessels and nerves that supply the abdominal viscera are enfolded within the primitive mesentery. The liver grows ventral from the gut within ventral plane. The spleen and pancreas and a major portion of gut grow within the dorsal plane.

7. Duodenal fossae PARADUODENAL FOSSA: Lies to the left of the duodenojejunal flexure. Occurs in 20%of persons. Never exist together with other types of duodenal fossae. BOUNDARIES: Above: pancreas & renal vessels Right : aorta Left : kidney Anterior : inferior mesenteric vein runs in the anterior wall of the fossa. If the fossa be the site of strangulated gut, its surgical enlargement can be effected in downward direction ,to avoid injury to inferior mesenteric vein.

8. duodenojejunal fossa Often coexist, formed by two peritoneal folds running to the left from the region of the termination of the duodenum. SUPERIOR DUODENOJEJUNAL FOSSA: Looks downwards. It is about 2-5cm in depth and in front of the 2 nd lumbar vertebra. INFERIOR DUODENOJEJUNAL FOSSA: Looks upwards. It is in front of the 3 rd lumbar vertebra.

9. Inferior duodenal fossa: This is an occasional opening which extends behind the 3 rd part of the duodenum. MESENTERICOPARIETAL FOSSA OF WALDEYER: The most usual position of this fossa is in the first part of the mesojejunum,immediately behind the superior mesenteric artery ,and immediately below the duodenum. It is bounded in front by superior mesenteric artery and behind by lumbar vertebra.

10. SITE OF OCCURRENCE: Foramen of Winslow A Defect in mesentery A Defect in transverse mesocolon Defects in the broad ligament Congenital or acquired diaphragmatic hernia. Duodenal retroperitoneal fossa-left paraduodenal & right duodenojejunal Ceacal /appendiceal retroperitoneal fossae- superior,inferior,retrocaecal Intersigmoid fossa.

11. Foramen of winslow

12. defect in the mesentery

13. Defects in the broad ligament

14. congenital Diaphragmatic hernia

15. Acquired diaphragmatic hernia

16. Duodenal retroperitoneal fossae

17. Caecal retroperitoneal fossae

18. Intersigmoid fossa

19. Acquired internal hernia It requires the formation of intra-abdominal aperture through which the bowel and other viscera may pass, Any rearrangement of intrabdominal organs creates a potential space through which bowel herniates. It includes mesenteric defect-created in bowel anastomosis . More common, most notably,are the multiple defects formed during a roux-en-y gastric bypass. Due to remarkable,increase in use of bariatric surgery for weight loss. The most common site for internal hernia after liver transplantation is through transverse mesocolon

20. ROUX-EN-Y GASTRIC BYPASS It can be done by open or laproscopic method. Proximal stomach is dissected between 1 st and 2 nd branches of left gastric branches. Stomach is transected at this proximal site to create a proximal gastric pouch(15ml if BMI>50;30 ml if BMI is 40-50) It is usually carried out through a linear stapler. Jejunum is transected 45cm from ligament of trietz . A side to side jejunojejunal anastomosis is done using a stapler 75 cm distal to distal cut end Proximal roux part of the distal jejunal cut part(75-150cm,based on the patients preoperative weight)is brought out through transverse mesocolon towards the created proximal gastric pouch .

21. Mesentric defect is closed. Stomal intergrity is checked on table by air distension and methylene blue infusion. Gastrograffin study is done in24hrs to assess pouch size,stomal patency and distal obstruction. There are two potential sited of herniation in any RYGB Defect in mesentry at Jejunojejunal anastomosis( brolin space). When roux limb transversus ,transverse colon aperture is created by crossing of two bowel mesenteries-PETERSON DEFECT Peterson defect is named after Peterson in 19 th century,described 2 cases of internal herniation posterior to loop gastrojejunostomy. There is evidence of decreased incidence of internal hernia with closure of every defect at initial operation. This is probably performed with non absorbable suture in running fashion.

22. Retrocolic approach was originally favoured due to fear of excess stretch on the gastrojejunal anastomosis with antecolic approach. Studies report increased incidence of internal hernia in retrocolic approach when compared to antecolic . This is due to mesenteric fat loss,that is inadequate to significantly widen mesenteric defects. Increased incidence of internal hernia with retrocolic approach is due to herniation through transverse mesocolic defect. Peterson defect is the most common site of herniation in antecolic approach to gastric bypass.

23. Laparscopic rygb Technique similar to open RYGB. Anastamoses are done using endoscopic stapler. GJ between gastric pouch and roux jejunum is done either using linear stapler through laparoscopic port after making a gastrotomy in the pouch ,which is later sutured after staple firing; or using circular stapler anastomosis is done,where anvil is initially passed transorally often under endoscopic guidance across the pouch into roux jejunum. Omentum is released from the colon and is covered over the GJ. Mesentric defect and Patterson brown defect are closed.

24. LRYGB was introduced in 1994. ADVANTAGES: Fewer wound infection Incisional hernia Splenic injuries Clinically significant adhesions Less post operative pain

25. DISADVANTAGES: Increased incidence of gastrojejunal anastomotic stricture. Internal hernia due to lack of adhesion formation and resulting mobility of the bowel. Re –operation after LRYGB IS 6.9% -13%,earlier it was 42%. Re-operations are two types -early and late. EARLY RE-OPERATIONS-within 90 days of initial operations. Most common indication-bowel obstruction or obstructive symptoms due to gastrojejunal stricture & obstruction at jejunojejunal anastomosis. LATE RE-OPERATIONS-after 90 days. Most common indication done for exploration secondary to pain,nausea,vomiting of unclear etiology.

26. Incidence of internal hernia after LRYGB is somewhere between 1.8%-7.6%. Internal hernia is indication for less than half of re-operations after LRYGB. Median time to re-operate for internal hernia ranges from 15-33.5months. Drastic weight loss is due to increased intra-abdominal pressure, bowel mobility, widening of previous mesenteric defects due to mesenteric fat loss. The average excess weight loss at the time of re-operation is 54%-90%.

27. Factors contributing to increased risk of internal hernia after laparoscopic approach . Lack of adhesion formation Increased incidence of small bowel mobility. Marked weight loss-induced ,increased mesenteric openings &failure to close all mesenteric defects appropriately.

28. Clinical features Symptoms of obstruction predominate in internal hernia. Cardinal clinical feature of acute obstruction Abdominal pain, Distension Vomiting Absolute constipation Roux limb obstruction most commonly results in ill-defined epigastric pain temporarily relieved with emesis. If bilious emesis is present it indicates obstruction beyond J-J anastamosis

29. PAIN Sudden onset, usually severe, colicky in nature, Usually centred on the umbilicus or lower abdomen The pain coincides with increased peristaltic activity. With increase in distension ,the colicky pain is replaced by a mild and more constant diffuse pain. If there is no ischemia and the obstruction persists over several days,pain reduces and can disappear. Development of severe, continuous pain not controlled with intravenous opiates is suggestive of strangulation

30. VOMITING The more distal the obstruction longer the interval between the onset of symptoms and the appearance of nausea and vomiting As obstruction progresses the character of the vomitus alters from digested food to faeculent material, as a result of presence of enteric bacterial overgrowth. DISTENSION: In small bowel, the degree of distension is dependent on the site of obstruction and is greater the more distal the lesion. Visible peristalsis may be present. Distension is a late feature in colonic obstruction and may be minimal or absent in the present of mesenteric vascular occlusion.

31. constipation Absolute constipation –neither faeces nor flatus is passed. Relative constipation-only flatus is passed. Absolute constipation is a cardinal feature of complete intestinal obstruction. Some patients may pass flatus or faeces after the onset of obstruction as a result of the evacuation of the distal bowel contents. The administration of enemas should be avoided in case of suspected obstruction. This merely stimulates evacuation of bowel contents distal to the obstruction and confuses the clinical picture.

32. The rule that absolute constipation is present in intestinal obstruction does not apply in: Richters hernia Gall stone ileus Mesenteric vascular occlusion Functional obstruction associated with pelvic abscess; All cases of partial obstruction (in which diarrhea may occur) Warning signs of bowel ischemia- tachycardia,fever,tenderness to palpation.

33. Laboratory examination is non diagnostic. Internal hernia patients – Amylasemia & leukocytosis Leukocytosis and physical examination findings necessitates early diagnostic laparoscopy if an alternative diagnosis is not clear. Lack of hernial sac in LRYGB, may be present in some form of congenital internal hernia , allows herniation of long segments of bowel leading to catastrophic ischemia.

34. imaging CECT has largely replaced any form of plain film studies with oral contrast due to its availability, speed & multiplanar formatting capabilities. Internal hernias often spontaneously reduce, it is important to image the symptomatic patient. Oral contrast –elucidate the etiology of obstruction. Internal hernia-typically proximal obstruction with out a pylorus to slow filling of small bowel. Thus small amount of oral contrast are sufficient if patient cannot tolerate typical dosage. Simply having the patient swallow,a tolerable amount of contrast on table immediately before scanning is adequate.

35. CT FINDINGS INDICATING POTENTIAL INTERNAL HERNIA: Aberrant vascular arrangement Clustering of bowel loops Signs of obstruction. SWIRL SIGN-occurs when tension on small bowel mesentry causes mesenteric vessels to twist around in a whorl like fashion & occurs in 55% of patients with internal hernia. Any abrupt changes in direction of mesenteric vessels or vascular engorgement are also concerning findings. Clusturing of bowel loops in aberrant location is indicative of obstruction.

36. Lateral clustering with displacement of colon ,mass effect on stomach, abnormal location of omentum,are all signs of potential internal hernia. CT signs of obstruction in a patient with potential for internal hernia necessitate diagnostic laparoscopy. Small bowel dilation is found in 25% of patients & mesenteric edema and free fluid are found in 11%.

37. repair Laparoscopic approach to exploration has been shown to be safe, through prior laparoscopic port sites. With patient in supine position or lithotomy position ,access is achieved through left sided port site initially. Identification of gastrojejunal anastomosis first, with atraumatic findings of laparoscopic graspers working distally to define roux- limb, mesocolic defect, Peterson space & the JJ anastomosis. Alternative approach-starting distally at terminal ileum ,to work proximally towards JJ anastomosis. Some prefer latter approach because the decompressed distal bowel is less tenuous to handle. Approaching from the opposite end will occasionally freeup a loop of previously trapped bowel.

38. It is also important to note that whether or not an internal hernia is found, the presence of defect itself is indication for closure of the defect. Closure is performed with nonabsorbable suture in running fashion. Signs of obstruction status-post spontaneous reduction include Dilated bowel Thickened mesentery Chylous ascites. Necrotic bowel is found in 8% of operations for internal hernia.

39. Internal hernia in pregnancy LRYGB is commonly performed in women of child bearing age. At times procedure itself is performed to increase fertility that has been ,repressed by pcos . Although general consensus is to delay pregnancy until 1 or 2 yr after LRYGB. studies have shown no difference in neonatal or maternal outcomes, regardless of whether pregnancy is attained during or after the period of maximal weight loss. Pregnant patients who present with LRYGB with abdominal pain are diagnostic challenge;& obstetricians need to be aware of the potential complication of LRYGB.

40. Right upper quadrant usg should be performed to asses the gallbladder pathology. Imaging that suggests remnant stomach dilatation should be potential sign for biliary limb obstruction. With low negative predictive value of CT & risk of radiation of the fetus, CT is not mandatory, prior to exploration. Laparoscopy is safe upto 31 weeks of gestation ,after this period open approach is preferred with some sources recommending mandatory CS after 36 weeks for both fetal safety and ease of exploration.

41. Congenital internal hernia The most common congenital hernia are Paraduodenal Pericecal Foramen of winslow Transmesenteric The term congenital is synonymous because these hernias often diagnosed later in life. Mortality associated with congenital hernia is inevitably due to delayed diagnosis & the septic complications of bowel ischemia.

42. Paraduodenal hernia Comprises 50% of all congenital internal hernia. Most common in men Despite their congenital in nature ,most common present in 3 rd or 4 th decades of life. Left sided (75%) & right sided (25%) are distinct in their pathogenesis. LEFT PARADUODENAL HERNIA Left Para duodenal hernia is defined as bowel herniating into potential space known as LANDZERT FOSSA

43. The space is typically obliterated during 5 th to 10 th week of gestation as the left colonic mesentry ,IMV, & ascending left colic artery fuse with retroperitoneum while small bowel is simultaneously undergoing its 270 degree counterclockwise rotation around SMA. Anterior border of this aperture- IMV,Ascending left colic artery, are displaced anteriorly. Anterior wall of hernia-left colonic mesentery. Afferent limb-4 th portion of duodenum. Efferent limb-as distal as ileum.

44. CLINICAL FEATURES: Variable Lifetime history of intermittent, self –resolving post prandial abdominal pain. Average age of diagnosis 38.5years. Upto 70% of the patients will have history of chronic abdominal pain. CT FINDINGS: Clustering of small bowel in the left upper quadrant with mass effect on posterior stomach & transverse colon and in few medial displacement of duodenojejunal junction. Clustering of vessels associated with loops of small bowel entering the sac may be apparent

45. repair Ideally simple reduction of the bowel & obliteration of , aperture with nonabsorbable suture prevents further herniation. If bowel is not easily reduced then herniotomy of the sac lateral to vessels may relieve edema ,allowing the reduction of the bowel. Adhesions are more likely to occur in intermittently inflamed sac of the bowel, so some advocate for ligation of IMV & Ascending colic artery involved in forming the aperture. Because this doesn’t increase the risk for left colonic ischemia. Prognosis & recovery depend upon the degree of herniation, strangulation & ischemia of involved bowel.

46. Right para duodenal hernia Right para duodenal hernia is defined as bowel herniation into potential space known as waldeyer fossa. The space is typically obliterated, as SMA & right colon mesentery fuse with retroperitoneum after passing over the third portion of duodenum. With interference of small bowel, the right colonic mesentery does not fuse to posterior abdominal wall, perpetuating the space known as waldyers fossa Anterior border of this aperture: SMA, Hepatic flexure & ascending colon. Afferent limb: 1 st segment of jejunum Efferent limb: distal as ileum if large herniation occurs.

47. CT FINDINGS: Clustering of small bowel loops in the right upper quadrant with displacement of descending duodenum superiorly & the transverse and ascending mesocolon anteriorly. REPAIR Similar to repair of left Para duodenal hernia with reduction and obliteration of the space. If unable to reduce the bowel, takedown of hepatic flexure will expose the hernia sac allowing herniotomy and potential decompression of the trapped bowel.

48. Foramen of winslow hernia 5-10% of all congenital hernia. The aperture in this case is natural entrance to lesser sac itself. Small bowel alone is contained in the sac in 2/3 rd of the patients. 1/3 rd - mobile ascending colon, that failed to fuse with abdominal side wall, herniating into space along with terminal ileum. Patients present with symptoms of proximal small bowel obstruction. Children may display tendency to draw their knees to their chest, which reduces tension across hepatoduodenal ligament.

49. CT FINDINGS: Loops of small bowel will be clustered posterior to stomach with anterior displacement of stomach. Stretched mesenteric vessels entering the lesser sac may be apparent. Herniated bowel is more superficially located in right upper quadrant with displacement of stomach instead of transverse colon. REPAIR: Reduction of contents into peritoneal cavity with possible aid from counter incision, this time to the left of hepatoduodenal ligaments into lesser sac. Case reports exist that describe suturing of the open aperture to the retroperitoneum, or pexy of the omentum, hepatic flexure or duodenum into the foramen to block the aperture.

50. Transmesenteric hernia Herniation through gap in the mesentery. Acquired type of trans mesenteric hernia occur after bowel anastomosis., congenital form is quite rare. It is most likely due to failure of proper mesenteric development secondary to ischemic insult in utero. Intestinal atresia is found in 50% of infants with transmesenteric hernia. Although this can occur anywhere along the length of the mesentery ,the most common encountered locations involve pericecal mesentery, sigmoid & duodenojejunal junction. 30% of cases remain asymptomatic throughout the life

51. Pericecal hernia Comprises 10%-15% of all congenital internal hernias. Due to failure of proper development of the pericecal mesentery ,due to ischemic event in utero, allows presence of an aperture through which small bowel may herniate. This aperture ,usually do not involve peritoneal cavity or sac ,significant length of small bowel may herniate quickly leading to strangulation CT FINDINGS: Loops of small bowel clustering lateral to cecum with anterior displacement of the cecum. REPAIR: Reduction of the herniated contents, closure of aperture &resection of necrotic bowel.

52. Intersigmoid hernia Comprises 5% of all congenital internal hernia. Improper development can lead to varying degree of defects in the sigmoid mesentery. Simply redundant sigmoid colon may also have redundant sigmoid mesentery which can form a pseudo sac into which bowel may herniate and be trapped. A defect in one leaf of the mesocolon may create a true sac which bowel can fill, blocked by the other leaf of mesentery. Lastly a through-and through mesenteric defect can obviously allow sizeable length of bowel to herniate. Diagnosis on imaging is difficult ,but loops of small bowel in the left lower quadrant that displaces the sigmoid colon anteriorly or medially may be apparent.

53. Trocar site hernia Incidence 0.2%-3%. Observed rarely with 5mm trocars, more frequently with use of 10mm ,12mm or bigger trocars especially with cutting or bladed trocars. Closure of fascial defects and use of non-cutting ,radial expanding trocars are recommended to decrease the risk of formation of trocar site hernia. Trocar site hernias can lead to small bowel obstruction early or late, after minimal access, intra-abdominal procedure.

54. Following laparoscopic procedure ,patient complains of pain in the region of trocar site, nausea, vomiting, should lead to investigation for a bowel obstruction. Commonly ,antimesenteric portion of the bowel wall will be incarcerated in the small fascial defect. These hernias are dangerous ,because they may result in strangulation and necrosis in the absence of intestinal obstruction. Reduction of necrotic bowel during hernia repair can result in missed perforation and peritonitis.

55. Congenital diaphragmatic hernia POSTEROLATERAL HERNIA: Occurs once in 2000 births & leads to herniation of abdominal contents into thoracic cavity, which compresses the lung and displaces the heart. Defective formation and fusion of the pleuroperitoneal membrane which closes the pleuroperitoneal canal in the fetus. Occurs more commonly in the left hemidiaphragm. Infants present with clinical triad of dyspnea, cyanosis , and apparent dextrocardia . The abdominal cavity is small, under developed & remain scaphoid after birth. Both the lungs are hypoplastic ,with decreased bronchial and pulmonary artery branching.

56. There is a surfactant deficiency ,which compounds the degree of respiratory insufficiency. Prenatal ultrasonography is successful in making the diagnosis of CDH as early as 15weeks of gestation. And antenatal diagnosis is associated with worst outcome. Diagnosis is made by chest x-ray.

57. TREATMENT: MEDICAL OPTIMIZATION: CDH was previously considered as a surgical emergency & infants typically underwent surgery in 1 st few hrs of life. A NG tube should be inserted to allow gastric and intestinal decompression Umbilical venous & arterial catheters are placed along with oxygen saturation probes in the pre and post ductal locations to allow for shunt estimation. Excessive stimuli can easily exacerbate pulmonary pressure and can lead to increased shunt flow/desaturations. For this reason infants are kept sedated with radiant warmer and external stimulation is limited.

58. Persistent pulmonary hypertension is the major factor increasing pulmonary resistance and causing right to left shunting with hypoxemia. ECMO requirement is seen in 10-20% of the infants. The goal of the therapy is to meet tissue oxygen demand while providing a period of rest for heart/lung during which the persistent fetal circulation can resolve. The current management involves early stabilization and delayed repair

59. There are few major principles of initial preoperative management: Minimizing the onset and impact of pulmonary hypertension. Gentle ventilation with permissive hypercapnia minimizes iatrogenic injury Imaging studies should be done to rule out associated anomalies. Surgical repair should be ideally delayed until the patient is hemodynamically stable for atleast 24hrs.

60. OPEN SURGICAL APPROACH: The traditional approach is through subcostal incision on the side of the defect. Bowel is reduced from the chest with gentle downward traction. Typically spleen and liver ,if present are the last organs to be reduced. Care should be taken during mobilization, as the spleen and liver may develop subcapsular hematoma and life threatening hemorrhage. If hernia sac is present ,it should be excised, to minimize the risk of recurrence. Anterior rim of the diaphragm is usually prominent ,posterior rim is typically diminished and obscured in the retroperitoneal fossa

61. The posterior diaphragmatic tissue must then be mobilized from the retroperitoneum, revealing the size of the defect. If adequate ,a primary repair with interrupted nonabsorbable suture material is preferred. If the size of the defect precludes primary closure ,use of prosthetic mesh is indicated. The most commonly used mesh is gore-tex . The use of prosthetic mesh has been associated with a higher risk of recurrence, especially with a larger initial defect.

62. THORACOSCOPIC APPROACH The first successful thoracoscopic repair in infant was reported in 1995. Initial opposition for thoracoscopic repair was due to the concern that high end tidal CO2 requiring increasingly high inspiratory pressures would worsen pulmonary hypertension. Potential advantages are improved cosmesis ,improved surgical field visualization, and avoidance of thoracotomy-associated musculoskeletal deformities. The operation is most often performed with a standard endotracheal tube . Due to the associated pulmonary hypoplasia, there is usually adequate room after the bowel is reduced to abdomen.

63. The infant is positioned in lateral decubitus position at the end of the bed. The veress needle is inserted in the 5 th intercostal space at the lower edge of the scapula , and low pressure co2 insufflation is used. Three ports are used and include 5mm port in the site of veress insertion.(4mm camera),3mm port in the left anterolateral chest wall(bowel grasper),5/3mm convertible port in the right posterolateral chest wall(bowel grasper, needle driver) The viscera are gently reduced with blunt graspers into the abdominal cavity. The defect is closed with interrupted nonabsorbable sutures, begining superior medially and inferior- laterally.

64. RETROSTERNAL HERNIA: The foramen of Morgagni are the names given to the openings which originally exist between the ventral( xiphisternal ) and the lateral (costal) slips of origin. When diaphragm is fully formed ,there is small natural space between these slips of origin. More common in right. Transmits superior epigastric vessels. Costal cartilages and sternum form the anterior boundary and diaphragm forms the rest of the circumference of the defect.

65. Repair is recommended in children, but asymptomatic hernia in adults are often observed. Laparoscopic repair with intracorporeal suturing is often performed , although sutures may also be placed transcutaneously and tied within a subcutaneous tunnel

66. Para- oesophageal or rolling hernia Defect in the diaphragm to the right and anterior to the oesophagus . There is a hernial sac present which usually contains the anterior wall of the stomach rolling upwards until it may be upside down in the posterior mediastinum. Normal relationship of the cardio- oesphageal junction to the diaphragm is undisturbed. This is a rare type of hernia, and the only way it can disturb the mechanics of esophagus is if by its bulk it compresses the esophagus against the vertebral column.

67. CLINICAL FEATURES: Abdominal pain, hiccough, early satiety, regurgitation, post-prandial bloating, dysphagia, dyspnea. INVESTIGATION: An upright radiograph of the chest may be diagnostic for para esophageal hernia, revealing the pathognomic retrocardiac air fluid level. Lateral radiograph usually demonstrates retrocardiac opacities . A radiograph demonstrating coiling of NG tube in a thorax can be used to demonstrate the presence of an intrathoracic stomach. TREATMENT: Excision of the sac and repair of the defect. Either abdominal or thoracic or laparoscopic approach can be used

68. Acquired diaphragmatic hernia TRAUMATIC HERNIA This may follow an open injury to the diaphragm as a result of penetrating wound on the chest or a closed injury to the diaphragm associated with sudden increase in intra-abdominal pressure following RTA. Hernia is usually through the left side of the diaphragm as the right side is protected by liver. The negative intra-thoracic pressure is responsible for sucking the stomach, small bowel, or colon into the chest. The defect in the diaphragm is repaired through the abdomen or the chest. The latter route is generally preferred if the herniated gut is thought to be densely adherent to the pleura

69. HIATAL HERNIA( SLIDING) This is the commonest of all internal hernia. The gastro- oesophageal junction is displaced into the chest ,but only the anterolateral portion of the herniated stomach is covered by peritoneum, so that stomach itself is not within a hernial sac. Incidence increases with age . Clinical features include chest pain, severe heartburn, abdominal pain ,difficulty in swallowing, belching, nausea Commonly diagnosed on barium meal examination. REPAIR: Removal of the sac, reduction of the contents ,closure of hernial orifice and fixation of the mobile organ. In this case closure of hiatal orifice cannot be complete and care must be exercised to avoid oesophgeal compression by excessive approximation of crura around the oesophagus .

70. references Shackel ford’s surgery of alimentary tract .8th edition , chapter74,page no 858- pg no 864. Maingot’s abdominal operations ,13 th edition pg 1711 Bailey and love’s short practice of surgery ,27 th edition. Shwartz’s principal of surgery 10 th edition . Lee McGregor’s synopsis of surgical anatomy,12 th edition. Peritoneal and retroperitoneal anatomy and its relevance for cross sectional imaging by Temel Tiirkes ,published in journal of Radiographics volume 39.number 3 .