Internal hernia

internal hernia

1. INTERNAL HERNIA

2. DEFINITION An internal hernia is defined as the protrusion of viscera through a normal or abnormal opening within the boundaries of the peritoneal cavity. Hernial orifice may be preexisting anatomic structure, a pathologic defect such as the foramen of Winslow, congenital or acquired origin

3. TYPES Foramen of winslow Paraduodenal (MC) pericecal , retrocaecal , transmesenteric , intersigmoid , and paravesical hernias.

4. PARADUODENAL HERNIA

5. PARADUODENAL HERNIA Pathogenisis : 1)Increased intraabdominal preasure pushes the bowel into potential sac 2)Congenital anomaly in development of peritonium that arises during midgut rotation Types Rt paraduodenal lt paraduodenal

6. PARADUODENAL HERNIA( lt ) Lt.paraduodenal hernia Ant Part of orifice is IMV,post part is post abd wall,contains most of small bowel Afferent limb-4 th part of duo Efferent limb-terminal part of ileum.

7. PARADUODENAL HERNIA( rt ) Here the ant part of hernia is sup mesentric artery

8. Symptoms Acute or intermittent small bowl obstruction pain,vomiting,distention,obstipation . Investigations X ray abdomen CT abdomen D lap Treatment Basic principles of hernia surgery, including reduction of the hernia contents, resection of the hernia sac, restoration of normal bowel anatomy, and repair of the hernia defect

9. TREATMENT If the small bowel is edematous, the hernia orifice is tight, or adhesions within the sac prevent manual reduction of the contents, the hernia orifice can be widened by excising the avascular plane to the right of the IMV. Care should be taken to avoid damage to this structure and the left colic artery, both of which lie in close proximity to the anterior edge of the orifice.

10. Transmesentric hernia Protrusion of a loop of bowel through the mesentery of the small bowel, the transverse mesocolon , the sigmoid mesocolon , or the falciform ligament. Congenital-associated with intestinal atresia , or mesenteric ischemia, Acquired-Most TMHs in adults are related to predisposing factors, including previous surgery, abdominal trauma, and peritonitis.

11. Symptoms Features of acute intestinal obstruction, rapidly progress into shock if associated with mesenteric ischemia and bowel necrosis. Diagnosis CT shows Mesenteric vessels may be stretched, crowded, engorged, and have a “whirl sign.”

12. Treatment Nasogastric decompression, aggressive preoperative fluid replacement, and correction of electrolyte disturbances are essential before surgical exploration. Abdominal exploration is mandated in all cases of TMH given the high incidence of incarceration and strangulation.

13. TRANSOMENTAL HERNIA Herniation of viscera,typically small bowel, through an opening in the gastrocolicomentum . The ring is formed entirely by the omentum . cause of the omental rent is unknown, but inflammatory, traumatic, circulatory,and congenital mechanisms have all been implicated.

14. Treatment Releasing the constricting ring by incising the omentum between clamps resecting or reducing the bowel, depending on its viability.

15. Hernia through epiploic foramen( Blandin hernia ) Aetiology large epiploic foramen, mobile cecum and ascending colon Contents small bowel (63%); cecum and right colon (30%); transverse colon (7%) gallbladder can also herniate

16. Treatment If the orifice is large reduce the hernia If the orifice is narrow and associated with edematous bowel loops the best option is controlled decompression of the distended bowel to avoid the vital structures that pass through the hepato duodenal ligament Fixation of the caecum can be done Usually here closure of the opening are not generally recommended,

17. Intersigmoid Here the orifice related to Lt Ureter,iliac vessels

18. Pericaecal,retrocaecal hernia

19. Retrocaecal hernia( hernia of Rieux ) caused by a partial defect of fixation of the right ascending mesocolon ( Toldt fascia). In this type of hernia, the viscera are trapped between the abdominal posterior peritoneum on the dorsal side, the cecum ventrally,and the right ascending mesocolon as the upper limit.

20. PERICAECAL HERNIA Superior ileocaecal hernia: In sup ileocaecal fossa formed by fold in sup ileocolic mesentry it contains ant branch ileocolic artery here the hernia sac travels under the right mesocolon . Inferior ileocaecal : The inferior ileocecal fossa has a prominent anterior ileoappendicular fold. This fold occasionally contains the ileoappendicular artery. The hernial sac is found under the cecum .

21. Acquired internal hernia Hernia in iatrogenically created defeact : 1)open and laparoscopic Roux-en-Y gastric bypass, 2) Billroth II gastrojejunostomy , 3) bilioenteric anastomosis , After the gastric bypass the hernia occur in 3 iatrogenically created space 1) the transverse mesocolon , 2)the divided small bowel mesentery, 3)the Petersen space that is located between the small bowel mesentery of the Roux limb and the transverse mesocolon .

22. Acquired internal hernia The mesocolic defect (arrow A), The Petersen defect (arrow B), a The enteroenterostomy defect (arrow C).

23. Roux en y gastric by pass

24. Diagnosis Gastric bypass patient with symptoms of nausea, vomiting, abdominal distention, and colicky postprandial abdominal pain should raise the suspicion of an internal hernia CT Shows: Mesenteric swirl sign

25. Diagnosis Gastric bypass patient with symptoms of nausea, vomiting, abdominal distention, and colicky postprandial abdominal pain should raise the suspicion of an internal hernia CT Shows:Mesenteric swirl sign

26. Treatment Confirmation by Diagnostic laparoscopy. Reduction of hernia by laparoscopy or open method Closure of defect by non-absorbable suture

27. High index of clinical suspicion along with prompt surgical management is required in internal hernia in order to avoid a potential abdominal catastrophe. THANK YOU …. Reference: Shackelford, internet