Internal hernias: anatomical basis and clinical relevance

Absence of Falciform Ligament Found During Laparoscopic Surgery: A Case Report

Anatomic variants of hepatic ligaments are rare, and complications attributable to these variants may be difficult to diagnose. Our aim is to contribute to the literature surrounding the incidental finding of a congenital absence of the falciform ligament. We report the case of a 37-year-old man who underwent a laparoscopic cholecystectomy for acute cholecystitis. During the operation, the patient was noted to have an apparent absence of the falciform ligament attachment to the liver. The round ligament was attached from the liver to the anterior abdominal wall at the level of the umbilicus. The round ligament is inserted into the inferior surface of the liver as a thick, cordlike structure encased in fat. In rare cases, the small intestine can pass through a falciform ligament defect and become trapped while remaining within the peritoneal cavity, leading to difficult-to-diagnose internal hernias. This condition can lead to intestinal obstruction, incarceration, and strangulation. This directed our decision to divide the remaining round ligament at the liver and close to the abdominal wall. When defects of hepatic ligaments are found incidentally during laparoscopic surgery, these investigators recommend that the operating surgeon consider dividing the remaining ligament as a protective procedure to prevent complications such as internal hernias, intestinal obstruction, incarceration, and strangulation.

Retroperitoneal cecal volvulus: a complication of a rare internal hernia - a case report

Introduction and importance

The foramen of Winslow hernia (FWH) is a rare type of internal hernia. In one-third of cases, the cecum was found in the lesser sac. More rarely, the herniated cecum might be volvulated, which represents 1-1.5% of the causes of intestinal obstruction. Once diagnosed, surgical reduction and/or resection of the nonviable herniated bowel is crucial for a positive outcome.

Case presentation

The authors report a case of retroperitoneal cecal volvulus that complicated FWH in a patient with a history of laparoscopic cholecystectomy.

Clinical discussion

A delay in the diagnosis is associated with high morbidity and even higher mortality. Because of lacking a consensus, the treatment of FWH depends on the team's surgical experience.

Conclusion

Reporting this case will help us to keep in mind this differential diagnosis while treating patients in our daily practice.

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

BACKGROUND

Considering 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 PRESENTATION

The 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.

CONCLUSION

Although 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.

Rare cause of chronic abdominal pain: left paraduodenal hernia and its surgical management

A 30-year-old man presented with colicky abdominal pain for 2 months, associated with occasional episodes of bilious vomiting. He had a history of similar complaints at the age of 16 and 26 years. Contrast-enhanced computed tomography abdomen was consistent with a diagnosis of left paraduodenal hernia. On laparoscopy a 3 × 3 cm hernial defect was identified in the left paraduodenal fossa (fossa of Landzert). Contents were jejunal, and proximal ileal loops which were dilated and edematous. Anterior border of the sac was formed by the inferior mesenteric vein and left branch of the left colic artery. Initial reduction of contents was easy. However, complete reduction proved to be difficult due to adhesions with the sac opening, the hernial sac instead laid open by dividing the Inferior Mesentric Vein (IMV) (anterior border of defect) using a vascular stapler. The patient was discharged on postoperative day 3 in a stable condition. On follow-up the patient is doing well.

Left Paraduodenal Hernia Presenting as Closed Loop Jejunal Obstruction in a Young Female: An Enigmatic and Perilous Differential of Acute Abdomen

Internal hernia is a rare cause of intestinal obstruction, accounting for <2% of cases with paraduodenal type being the most common. An internal hernia, mostly acquired, develops due to protuberance of the intestine through a gap in the peritoneum or mesentery formed as a result of an antecedent abdominal operation such as gastric bypass or liver transplant, ischemic injury, peritonitis, or trauma. Paraduodenal hernias (PDHs) are congenital anomalies, secondary to a failed fusion of mesentery with parietal peritoneum along with rotational midgut errors, causing the evolution of potential space for herniation within the left paraduodenal fossa. Primary internal hernias can have a varied clinical presentation and cause significant mortality and morbidity if left untreated. We report the case of a 20-year-old female with chronic pain in abdomen and intestinal obstruction due to left PDH (LPDH). The prompt diagnosis led to timely exploration and reduction of entrapped jejunum, with prudent closure of the hiatus, while circumventing any injury to the adjacent mesenteric circulation. No postoperative ileus arose, and recovery was uneventful.

Internal herniation of the caecum and the ascending colon through the foramen of Winslow

We are reporting a case of internal herniation of the bowel through the foramen of Winslow. This is a very rare condition that prompts an urgent operative intervention due to its potential fatal complications, as it is usually accompanied by bowel strangulation and ischemia. Due to the vague clinical picture, the diagnosis only reached using imaging techniques such as computed tomography or as a surgical surprise during the operation. Key aspects of surgical interventions are hernia reduction, bowel resection in case of non-viable ischemic bowel and the highly debatable recurrence prevention maneouvres.

A paraduodenal hernia revealed by bowel obstruction: case report and literature review

Internal hernias are defined as the protrusion of abdominal viscera through an aperture in the intraperitoneal recesses, they are considered as a rare cause of intestinal obstruction. The paraduodenal hernias are the most common type of congenital hernia especially the left-sided ones. We report a case of a 46 year-old man presenting a left paraduodenal hernia with acute small bowel obstruction, which was firstly (preoperatively) assigned to a tumoral cause.

Paraduodenal hernias: a systematic review of the literature

PURPOSE

Paraduodenal hernias (PDH), also called mesocolic hernias, account for up to 53% of all internal hernias, but they cause only 0.2-0.9% of all cases of intestinal obstruction. This is the first systematic review of all reported cases so far, investigating their clinical presentation, radiological imaging, and treatment outcomes.

METHODS

After a detailed search in PubMed and Medline, using the keywords "paraduodenal hernia", 115 studies matched our criteria. A review of these reports was conducted and the full texts were examined.

RESULTS

A total of 159 patients were included in our analysis, with 69.8% and 30.2% of them suffering from either a left or a right PDH, respectively. Mean age at diagnosis was 44.1 years, with a 2/1 male/female ratio. PDH were associated with non-specific symptoms and signs; abdominal pain being the most common. Computed tomography (CT) scan of the abdomen was the most frequently used diagnostic modality. Regardless of PDH localization, all patients were operated on, with approximately one-third of them undergoing a laparoscopic operation, which was associated with a significantly decreased morbidity rate as well as length of hospital stay, compared with the open repair.

CONCLUSIONS

PDH are not usually associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of knowledge and clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair, seeming to be the optimum treatment strategy.

Laparoscopic management of cecum and ascending colon hernia through the foramen of Winslow

Herniation of gastrointestinal structures through the foramen of Winslow is rare, with patients presenting with nonspecific symptoms. We describe a 47-year-old woman who presented with generalized, intermittent, colicky abdominal pain for a duration of 4 days. An abdominal computed tomography scan revealed findings consistent with herniation of the ileocecal junction through the foramen of Winslow. Laparoscopic assisted internal hernia reduction with ileocecal resection and side-to-side ileocolic anastomosis were done. The cecum and terminal ileum were resected due to signs of ischemia. Her postoperative was uneventful, and she was discharged in the second postoperative day. She did not show any signs or symptoms suggestive of complications or recurrence during her follow-up.

[Internal hernia through the falciform ligament: a rare cause of intestinal obstruction]

Internal hernias are a rare cause of acute intestinal obstruction. Hernias through the falciform ligament is uncommon. Diagnosis is often made intraoperatively. Abdominal CT scan, performed in an emergency situation, can enable preoperative diagnosis and guide the therapeutic approach. In this respect, we here report a case whose data were collected in the Department of Visceral Surgery at the University Hospital Hassan II in Fez. The study involved a 48-year old patient, with no particular previous history, admitted to the Emergency Department with occlusion evolving over 4 days. Abdominal x-ray without treatment objectified multiple hydroaeric levels in small bowel some of which projected towards the hepatic region as well as the presence of a flat intestinal loop in continuity with distended intestinal segment. Abdominal CT scan was not performed due to altered renal function. The patient then underwent emergency surgery after stabilization of his condition and the diagnosis of internal hernias through the falciform ligament was made intraoperatively. In adults, internal hernia through the falciform ligament is a rare cause of acute intestinal obstruction in our daily practice. The diagnosis is most often made intraoperatively. It is necessary to suspect it in young patients with no history of abdominal surgery or intraperitoneal infectious process and with hydroaeric levels in the right upper quadrant.

Small bowel obstruction secondary to left paraduodenal hernia: A case report and literature review

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Congenital internal hernias are an infrequent condition resulting from the protrusion of abdominal organ through an intra-peritoneal defect.

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Left paraduodenal hernia is the most common types of congenital internal hernias.

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Landzert fossa is bounded by the fourth part of the duodenum from the right, the posterior peritoneum posteriorly, the inferior mesenteric vein, and left branches of the middle colic artery anteriorly.

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Laparotomy is mandated in cases of intestinal perforations, necrosis and hemodynamic instability.

Introduction

Internal hernias are uncommon and are defined by the protrusion of a viscus through intraperitoneal defects. Left paraduodenal hernias (LPDH) are the most common type of congenital internal hernia (CIH).

We report a clinical case of a patient with a small bowel obstruction (SBO) due to a LPDH.

Case presentation

An elderly patient, with negative surgical history, presented to the emergency room with abdominal pain and vomiting. Clinical and radiologic investigations were consistent with SBO due to an internal hernia. During laparotomy, a large LPDH containing dilated small bowel loops was identified. The hernia contents were reduced and the opening was closed with non-absorbable sutures. The post-operative course was uneventful without signs of recurrence at follow up.

Discussion

LPDH result from absence of retroperitoneal fixation of the descending colon mesentery. Usually, patients are asymptomatic and LPDH are incidental findings detected on imaging and/or during laparotomy. However, LPDH may lead to acute SBO therefore a high index of clinical suspicion and preoperative imaging is crucial to make an early diagnosis.

Conclusion

CIH is a rare condition due to embryologic developmental abnormalities. Their diagnosis is based on pathognomonic findings on computed tomography scanner (CTscan). Surgical treatment is the mainstay treatment. Delay diagnosis of strangulated CIH is associated with significant morbidity andmortality.

A Rare Cause of Obstructive Jaundice: Cecal Herniation through the Foramen of Winslow

Internal abdominal hernias are rarely reported in the literature and have a very low rate of preoperative diagnosis. It is even rarer that they present with jaundice. A 59-year-old Caucasian female presented with a short history of jaundice, dark urine, epigastric pain, vomiting, and obstipation. Her liver biochemistry profile revealed a mixed cholestatic/hepatocellular pattern with significantly elevated bilirubin. She urgently underwent abdominal imaging which provided a preoperative diagnosis of internal herniation of the cecum within the lesser sac through the foramen of Winslow. The dilated bowel was compressing the common bile duct explaining the jaundice. This was repaired intraoperatively by anchoring the mobile cecum. In this case, we highlight the importance of maintaining a high index of suspicion for internal herniation on abdominal imaging with clinical evidence of intestinal obstruction. A foramen of Winslow hernia should be further suspected in the presence of jaundice.

Para-duodenal hernia: a report of five cases and review of literature

BACKGROUND

Para-duodenal hernia (PDH) represents rare clinical entities based on few literatures.

CASE PRESENTATION

We report five cases of Para-duodenal hernia, all occurring in male patients ranging from 34 to 75 years of age. The patients had varied manifestations presenting with abdominal pain with or without vomiting and nausea and with or without signs of intestinal obstruction. CT images showed cluster of dilated bowel segments with displaced mesenteric vessels at hernial orifice. Laparoscopic surgical approach was adopted, and the patients were discharged about a week later without further complications.

CONCLUSION

We hope to raise awareness about the management of this rare clinical entity and the benefits of CT imaging and laparoscopic surgery as standard approaches.

Left Paraduodenal Hernia: A Rare Complication following Laparoscopic Appendectomy

Paraduodenal hernias are rare congenital internal hernias accounting for <2% of intestinal obstruction. Left paraduodenal hernias (LPDHs) into the fossa of Landzert are the more common type and result from abnormal rotation of the midgut and failure of peritoneal fusion. Sequelae of these hernias usually occur spontaneously in the 4th or 5th decade of life and are more common in males and have a significant risk of incarceration and subsequent strangulation. We describe a case of a 15-year-old female who develops a LPDH following laparoscopic appendectomy, resulting in jejunal incarceration and subsequent small intestinal obstruction. The patient discussed is from an atypical demographic, being young and female. In addition, the precipitating event prompting incarceration of the hernia appears to be the application of pneumoperitoneum, placement in the Trendelenburg position, and manipulation of small intestine for the purpose of facilitating laparoscopic appendectomy. To our knowledge, this is the first reported case of LPDH exacerbated by laparoscopic procedure.

Case of a strangulated right paraduodenal fossa hernia in a malrotated gut

We report an unusual case of a strangulated internal hernia resulting from a right paraduodenal fossa hernia (PDH) in the context of bowel malrotation. There are few documented cases of PDHs associated with a concomitant gut malrotation. Emergency laparotomy was performed based on clinical and radiological. Intraoperatively, the proximal jejunum was seen to enter a hernia sac formed by an aberrant duodenojejunal flexure located to the right of the aorta. This was presumed to be a strangulated internal hernia of the paraduodenal recess in a malrotated gut. The hernia neck was widened and the sac obliterated to allow reduction of the contents. On reduction and warming, the insulted small bowel appeared viable and returned to the abdominal cavity without resection.

The "pouch" of the Douglas's pouch

Hernia is described as the protrusion of an organ into the wall of its normal containing cavity. Internal hernia (IH) involves protrusion of viscera through: a peritoneal or mesentery defect, a normal or abnormal compartment of the peritoneal cavity. Hernias occurring in the pelvis cavity are usually classified according to the fascial margins breached and include sciatic, obturator and those through the rectouterin pouch: elytrocele and enterocele. Those hernias are defined by the protrusion of a viscus through the wall of the pelvis due to weakness of the pelvic fascia and/or muscles. Pelvic hernia through the pouch of Douglas (PD) involves the genital tract in female (elytrocele and enterocele). Sometimes described in the literature as Douglas hernia, this type of hernia must be distinguished from the conventional IH. As defined before, the borders to be considered for IH is the peritoneal membrane, which is not a real solid wall but delimitates the peritoneal cavity; and there is no peritoneal defect in elytrocele or enterocele. A PubMed search for IH through a defect in the peritoneal PD revealed only five female cases, making this an extremely rare condition. To our knowledge, we have presented here the only published case in a male. This probably congenital and morphologic anomaly (defect) of pouch of Sir Douglas must be distinguished as the real "Douglas IH". Authors discuss the concept of a new and more detailed classification of IH.

Rare Hernias Presenting as Acute Abdomen- A Case Series

Hernia is an abnormal protrusion of an organ or tissue through a defect in its surrounding walls. It can be divided into internal, external and diaphragmatic hernias. Most of them can be asymptomatic. If they become symptomatic they can present with features of intestinal obstruction, incarceration or strangulation. In this case series we compare the incidence of these rare presentations of hernias with world literature and to warn surgeons not to cut the obstructing band in cases of internal hernias. In this case series, we review the clinical details of 7 rare presentations of hernia, who presented with various types of hernias to a tertiary care centre in Kerala over a period of one year. Of these 7 cases 6 cases were internal hernias (3 left paraduodenal hernias, 2 transmesentric hernias, and 1 pericaecal hernia) and a case of spigelian hernia above the level of umbilicus. All of them presented as acute abdomen in the emergency department. Among these 7 cases, only one case was diagnosed preoperatively. Three patients had bowel gangrene and had to undergo resection- anastomosis of the bowel. The survival rate among these cases was 100% as compared to 50% in the world literature if they had been left untreated. Even though internal hernias are a rare entity, we need to have it as a differential diagnosis in case of intestinal obstruction, in a previously non-operated abdomen.

Difficult diagnosis: internal herniation of the terminal ileum through the foramen of Winslow into the lesser sac

Herniation of the bowel through the foramen of Winslow is rare and accounts for 8% of all internal herniae. It typically presents clinically and biochemically as small bowel obstruction. It carries a high mortality as diagnosis is often delayed, despite bowel strangulation, as clinical signs are not typical and imaging may not be diagnostic. In the case presented here, a healthy 25-year-old man was admitted with sudden onset right-sided abdominal and back pain. He denied vomiting, and had opened his bowels. His bloods were normal and venous lactate <2; CT was not diagnostic. At laparotomy, he was found to have internal herniation of the terminal ileum through the foramen of Winslow, which was gangrenous and required resection. This paper discusses the difficulty in diagnosing internal herniation and poses the question as to whether we are too dependent on CT findings in the setting of an acute abdomen.

Intestinal obstruction secondary to left paraduodenal hernia

An internal hernia—congenital or acquired—is a protrusion of bowel through an opening in the peritoneum or mesentery. Internal hernias are the etiology of <2% of intestinal obstructions, with paraduodenal hernias being the most common type of congenital internal hernia. We report a case of a left paraduodenal hernia (LPDH) combined with partial small bowel obstruction in a 69-year-old male with recurrent abdominal pain of 2 years duration and no previous abdominal surgeries. An abdominal computed tomography scan showed an agglomeration of small bowel loops in the left upper quadrant but failed to yield a clear diagnosis. Surgical intervention provided definitive diagnosis and treatment of the LPDH. We additionally review the literature regarding anatomy, pathogenesis, diagnosis and treatment of this uncommon hernia. Intestinal obstruction secondary to an internal hernia is a rare entity; however, delayed diagnosis and surgical intervention may result in significant morbidity and mortality.

Internal hernia through the foramen of Winslow: a diagnosis to consider in moderate epigastric pain

Herniation through the foramen of Winslow is a rare condition that can lead to a delayed diagnosis and treatment with a high mortality rate. In most reported cases, patients present to the emergency department with symptoms suggesting intestinal obstruction or with sudden and severe pain in the upper abdomen. Symptoms are non-specific. Clinical diagnosis may be difficult or even missed. The widespread availability of cross-sectional imaging can improve the percentage of correct preoperative diagnosis. We report a case of a caecal and right colic herniation through the foramen of Winslow found incidentally on abdominal computed tomography in a patient presenting with mild epigastric pain.

Herniation of the gravid uterus through a mesoduodenal defect and concurrent omental hernia in a cow

OBJECTIVES

To describe surgical treatment of herniation of the gravid uterus through the mesoduodenum, displacement of the descending duodenum around the gravid uterus, and concurrent herniation of the small and large intestines into the omental bursa in a cow.

STUDY DESIGN

Clinical report.

ANIMAL

Three-year-old, five-month-pregnant Swiss Braunvieh cow.

METHODS

Repositioning of the displaced uterus and descending duodenum without transection and anastomosis of the duodenum was performed through a right flank laparotomy. Concurrent displacement of a large portion of the small and large intestines into the omental bursa was not associated with intestinal strangulation and was corrected manually. The defects in the omentum and mesoduodenum were sutured.

RESULTS

There were no postoperative complications, and the cow was healthy at discharge from the clinic 1 week after surgery. Telephone follow-up revealed that the cow had delivered a live calf and was producing a normal amount of milk. The cow was slaughtered 14 months after the surgery because of an udder problem.

CONCLUSIONS

Herniation of the gravid uterus through a tear in the mesoduodenum with subsequent displacement of the descending duodenum around the uterus combined with internal omental herniation caused nonspecific clinical signs and no ileus. Exploratory laparotomy in an early stage of pregnancy facilitated reduction of the displaced uterus without transection of the descending duodenum.

Post-operative internal hernia through an orifice underneath the right common iliac artery after Dargent's operation

We report the case of a 39-year-old woman with ileus resulting from a small bowel incarceration underneath the right common iliac artery. The patient had a history of a radical trachelectomy with laparoscopic pelvic lymphadenectomy ("Dargent's operation") for cervical carcinoma. After dissection of the iliac vessels, a small bowel loop could slide underneath the common iliac artery. The hernia was closed by gluing a collagen patch over the right common iliac artery onto the retroperitoneal cavity. To our knowledge, such a case has not previously been reported in the medical literature.

Internal herniation of the small and large intestines in 18 cattle

Internal intestinal hernia was diagnosed during laparotomy in 18 cattle with a tentative diagnosis of ileus; the diagnosis was made during a second laparotomy in two cases. In 14 cattle, the hernial orifice was in the visceral layer of the greater omentum and the intestines had herniated into the caudal recess of the omental bursa. In two animals both the visceral and parietal layers had an opening; in one, the orifice was in the mesoduodenum, and in the other in the mesojejunum. The length of the hernial orifice ranged from 3 to >25 cm and the length of the herniated intestine ranged from 30 cm to the entire length of the small and large intestines. The omental rents were located near the caudal flexure of the duodenum (n=9), ventrally near the rumen (n=6) or in both of these locations (n=1). Seven cattle were euthanased intraoperatively because of incarceration of the jejunum; three of these had ruptured intestines and localised peritonitis; another animal was euthanased following a second laparotomy because of peritonitis. Ten animals, two of which underwent jejunal resection-anastomosis, recovered and were discharged. Nine of these survived a 6-month-postoperative period (mean ± SD: 27 ± 18 months) and remained free of colic, and one was slaughtered 3 months postoperatively because of rupture of the mammary suspensory ligament.

Diagnosis and treatment of symptomatic right paraduodenal hernia: report of a case

We report a typical case of right paraduodenal hernia (RPH) and review the literature on the pathogenesis, diagnosis and treatment of this uncommon entity. A 32-year-old woman was hospitalized with acute abdominal cramps, nausea, and vomiting. Computed tomography (CT) findings suggested RPH, which was confirmed by explorative laparoscopy. We performed an open repair by suturing the orifice after reducing the hernia. At her 2-year follow-up, the patient reported complete resolution of her symptoms. Because RPH is rare and its clinical signs are nonspecific, radiological examinations are essential for a correct preoperative diagnosis. CT is currently the most accurate diagnostic tool, but laparoscopy may be necessary to confirm the diagnosis. This hernia can be repaired by simple suturing of the hernial orifice, either laparoscopically or via an open procedure, although several authors consider complete intestinal derotation to be the best option.

Acute intestinal obstruction secondary to left paraduodenal hernia: a case report and literature review

Introduction

An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Although they are considered as a rare cause of intestinal obstruction, paraduodenal hernias are the most common type of congenital hernias.

Methods

A literature search using PubMed was performed to identify all published cases of left paraduodenal hernia (LPDH).

Results

In Literature search between 1980 and 2012 using PubMed revealed only 44 case reports before the present one. Median age was 47 years (range 18 – 82 years). Nearly 50% reported previous mild symptoms. Two-third of patients required emergency surgery in form of laparotomy or laparoscopic repair. Reduction of hernia contents with widening or suture repair of the hernia orifice were the most common standards in surgical management of LPDH.

Conclusion

Intestinal obstruction secondary to internal hernias is a rare presentation. High index of suspicion and preoperative imaging are essential to make an early diagnosis in order to improve outcome.

A mesenteric hernia complicated with a triple necrotic volvulus

A 6-year-old girl was admitted to the paediatric emergency department with colicky abdominal pain. She had a significant medical history, with four previous admissions due to recurrent abdominal pain in the past year. On examination the abdomen was soft, there was no rebound tenderness and Rovsing's sign was negative. Her blood tests revealed a raised white cells count, although her C reactive protein was within the normal range. Abdominal x-ray revealed small bowel obstruction. During her assessment the patient rapidly deteriorated and seemed to go into shock. Her clinical state in addition to the radiological findings meant that she was taken to theatre for surgical exploration. This showed a triple volvulus with necrotic bowel loops that had herniated through a mesenteric defect. The necrotic bowel was subsequently resected.

Caecal herniation through the foramen of Winslow: a rare cause of bowel obstruction

Internal herniation through the foramen of Winslow is a rare cause of abdominal hernia. We describe a case in which caecal herniation through the foramen of Winslow was diagnosed using various imaging modalities, including computed tomography and managed operatively through hernia identification, caecal reduction and foramen closure. The literature is subsequently reviewed to highlight previous similar episodes and identify the optimal modalities for pre-operative diagnosis and describe the most appropriate intra-operative management.

Spontaneous internal herniation through the greater omentum

Internal hernia is an unusual cause of intestinal obstruction, and the through sites of hernias may include the paraduodenum, transmesenteric region, foramen of Winslow, paracecum, the broad ligament of the uterus, and the transomental region. Transomental hernia is the rarest type of internal hernia and accounts for fewer than 1% of internal hernias. Transmesenteric and transomental hernias are different from the other types of internal hernia, and usually present acute intestinal obstruction with strangulation of the small bowel. We report a 74-year-old male with initial manifestation of peritonitis. Internal hernia-induced intestinal obstruction with strangulation was highly suspected from the image study. After an urgent exploratory laparotomy, transomental hernia was diagnosed.

A transmesenteric hernia in a child: gangrene of a long segment of small bowel through a large mesenteric defect

Intestinal obstruction is a common surgical emergency. Transmesenteric hernia is an unusual cause of bowel obstruction that may result in irreversible damage of the bowel and a fatal outcome. Once incarceration of the bowel occurs, strangulation and gangrene follow immediately. The mortality rate associated with this condition is about 15%, but in the presence of gangrene of the bowel, the mortality rate is more than 50%. An accurate preoperative diagnosis of a transmesenteric hernia is very difficult and rarely made. Therefore, in patients with small bowel obstruction, in the absence of a history of previous surgery to suggest adhesions or an external hernia, the possibility of a transmesenteric hernia must be considered. We describe a case with gangrene of a long segment of the small bowel caused by a transmesenteric hernia through a large defect of small bowel mesentery in a child.

Large congenital transmesenteric hernia: a missed small-bowel atresia?

Internal hernias are uncommon diagnoses and represent rare causes of intestinal obstruction. Diagnoses are frequently made perioperatively. We present herein an illustrated case of transmesenteric hernia diagnosed in a pregnant woman who consulted for severe abdominal and dorsal pains. As CT scan was not possible because of the obstetric history, a decision to perform surgery was made because of acute pain, no history of previous surgery, and a plain erect X-ray disclosing early signs of intestinal obstruction. Perioperative findings were an ileal volvulus through a transmesenteric fossa circled by a unique ileocolic branch. This particular vascular disposition suggests transmesenteric hernias may be the first step in the constitution of congenital small-bowel atresia.