Review of internal hernias: radiographic and clinical findings

Complication of Internal Herniation-related Bowel Obstruction Post-Single Anastomosis Sleeve Ileal (SASI) Bypass and Management: Series Case Sharing (Video Report)

BACKGROUND

Obesity is a global health concern associated with multiple comorbidities, and bariatric surgery remains one of the most effective interventions for sustained weight loss and metabolic improvement. The Single Anastomosis Sleeve Ileal (SASI) bypass is a novel procedure that offers a simplified surgical approach while maintaining efficacy. However, despite its advantages, SASI bypass carries a risk of postoperative complications, including internal herniation-related bowel obstruction-a rare but potentially life-threatening condition requiring prompt recognition and intervention.

METHOD

We report 3 cases of internal herniation following SASI bypass, 2 performed robotically and 1 laparoscopically. Despite uneventful surgical procedures, all 3 patients developed postoperative internal herniation, with symptom onset ranging from 1 week to 16 months after surgery. A comparative summary of their clinical presentations and outcomes is provided in the accompanying table. Due to timely diagnosis and prompt surgical intervention, all patients had favorable outcomes. In addition, we compiled and edited a surgical video from the third case to illustrate the operative management of this complication.

RESULTS

Computed tomography (CT) emerged as the gold standard for diagnosis, although immediate surgical exploration was necessary in cases of peritonitis or hemodynamic instability. Notably, 1 patient (Case 2) experienced rapid weight loss, a factor previously implicated as a potential risk for internal herniation. Petersen's defect was the most common herniation site in SASI bypass, resembling the pattern seen in One Anastomosis Gastric Bypass (OAGB) but differing from Roux-en-Y Gastric Bypass (RYGB), where multiple mesenteric defects increase the risk. While a longer biliopancreatic limb may predispose SASI and OAGB patients to herniation, consensus on routine defect closure remains lacking.

CONCLUSION

Internal herniation is a rare but serious complication of SASI bypass, with delayed diagnosis potentially leading to bowel ischemia or perforation. CT is essential for early detection, while timely surgical intervention is critical in symptomatic cases. The necessity of routine Petersen's defect closure remains debated, highlighting the need for further studies to determine the true incidence and optimal prevention strategies.

Clinical characteristics of neonatal mesenteric hiatal hernia

BACKGROUND

Neonatal mesenteric hiatal hernia (MHH) is a rare but serious congenital abnormality. Due to the lack of specific clinical features, it poses challenges for diagnosis and treatment. Early identification and timely intervention are crucial for improving neonatal outcomes. This study aims to explore the clinical characteristics, diagnostic methods, and treatment outcomes of neonatal MHH.

METHODS

A retrospective analysis was conducted on seven cases of neonatal MHH admitted to the First Department of General Surgery at Hebei Children's Hospital from January 1, 2010, to September 30, 2024. General information, clinical data, examination results, and surgical conditions of the patients were collected and analyzed.

RESULTS

The average hospital stay for the seven neonatal MHH patients was 16.57 days. No complications such as bowel obstruction were observed during the 12 to 24 months of postoperative follow-up. The clinical symptoms were primarily abdominal distension, with some patients also presenting with vomiting, abdominal pain, and other symptoms. The imaging examinations showed that most patients exhibited signs of bowel obstruction and some CT scans revealed features such as bowel loop aggregation and mesenteric vascular abnormalities. Laboratory tests indicated mild inflammation and slight functional abnormalities in some organs. Regarding surgery, five patients underwent conversion to open surgery. The hernia defects were mainly located at the terminal ileum and ileocecal junction. Six patients required bowel resection due to bowel necrosis and four of them underwent ostomy procedures. All patients recovered well postoperatively.

CONCLUSION

Neonatal MHH is a rare and complex condition, with imaging playing a key role in early diagnosis. Laparoscopic surgery is the preferred treatment method due to its minimal invasiveness and quick recovery. Future efforts should focus on enhancing clinical awareness of this condition and integrating clinical symptoms with relevant examinations to improve early diagnosis and treatment outcomes.

Real-time ancillary diagnostics for intraoperative assessment of intestinal viability in horses-looking for answers across species

Clinical intestinal viability assessment is associated with significant limitations, and there is an undisputable need for ancillary diagnostics during colic surgery. Human and companion animal surgeons struggle with similar intraoperative issues, yet there is little exchange between specialists. Therefore, this narrative review aimed to create an overview of real-time ancillary diagnostics with the potential for intraoperative intestinal viability assessment in horses. Most real-time ancillary diagnostics can be classified as either tissue perfusion or oxygenation assessments. Intestinal perfusion may be quantified using dark field microscopy, laser Doppler flowmetry, or fluorescence angiography (FA). In particular, indocyanine green FA has gained popularity in human medicine and is increasingly employed to predict intestinal injury. Intestinal oxygen saturation can be measured by pulse oximetry or mixed tissue oximetry. The latter can be conducted using visible light or near-infrared spectrophotometry, and these measurements correlate with clinical outcomes in various species. Other real-time diagnostics include thermography and techniques currently under development, such as laser speckle flowgraphy or photoacoustic imaging. The modalities discussed are minimally invasive and may be used for intraoperative assessments of the intestine. However, limitations include the occurrence of artifacts and the subjective nature of some modalities. Techniques such as indocyanine green FA and tissue oximetry are already available in veterinary practice and have the potential for use during colic surgery. However, blinded clinical trials are lacking in all species, and more research is needed to determine the accuracy and cutoff values in equine-specific intestinal lesions.

Surgery-confirmed internal hernia with or without Roux-en-Y anastomosis: diagnostic performance of six CT signs

PURPOSE

To assess the diagnostic performance and generalizability of established CT signs of internal hernias across a broad patient population including those with and without Roux-en Y anastomosis.

METHODS

Our institutional review board approved this retrospective study. CT scans of 21 patients (11 women, 10 men) with surgically confirmed internal hernia and 52 control patients (23 women, 29 men) in whom internal hernia was suspected on CT but subsequently excluded surgically were reviewed. Six CT signs were evaluated: non-duodenal small bowel (ND-SB) behind the superior mesenteric artery (SMA), right-sided jejunojejunal anastomosis in applicable patients, "swirl" sign, superior mesenteric vein compression, "mushroom" sign, and clustered small bowel (SB) loops. Sensitivity, specificity, and odds ratios with 95% confidence intervals were calculated for each sign using logistic regression.

RESULTS

Logistic regression identified the "mushroom" sign, clustered SB, and ND-SB behind the SMA as significant independent predictors of internal hernia with an area under the receiver operating characteristic curve of 0.746. The sensitivity, specificity, and odds ratio of the "mushroom" sign, clustered SB, and ND-SB behind the SMA were 38.1%, 86.5%, 3.96 (95% CI, 1.21-12.97), 47.6%, 75.0%, 2.73 (95% CI, 0.94-7.89), and 33.3%, 88.2%, 3.75 (95% CI, 1.08-13.02), respectively.

CONCLUSION

The "mushroom" sign, clustered SB, and ND-SB behind the SMA are valuable CT findings in diagnosing internal hernias irrespective of Roux-en-Y anastomosis. In particular, ND-SB behind the SMA and the "mushroom" sign are highly specific.

Intestinal obstruction in a patient with congenital transverse mesocolic defect with internal hernia: A case report

INTRODUCTION AND IMPORTANCE

Internal hernias (IH) account for 5.8 % of all cases of intestinal obstruction. Intestinal obstruction due to congenital transverse mesocolic defects is a rare but significant clinical challenge that requires prompt recognition and surgical intervention.

CASE DISCUSSION

A 71-year-old female with COPD presented with acute abdominal pain, abdominal distension, and vomiting. On physical examination, the abdomen was distended with generalized tenderness. Contrast-enhanced computed tomography (CECT) revealed a transition point at the ileum. Failure of conservative management led to exploratory laparotomy that revealed a 7 cm ∗ 6 cm defect in the transverse mesocolon with herniation of ileal loops into the lesser sac. The hernia was reduced, and the defect closed. Postoperatively, the patient recovered well without complications.

CLINICAL DISCUSSION

IH, including transverse mesocolic IH (TMIH), are often asymptomatic or present with vague abdominal pain. They are challenging to diagnose clinically and radiologically. It has been reported in several studies, with internal hernias due to mesocolic defects accounting for about 0.2-0.9 % of all abdominal hernias. CECT offers a diagnostic accuracy of 77 %. Surgical intervention is necessary for complicated cases, with a focus on reducing the herniated bowel and closing the defect. This case highlights the importance of considering congenital mesocolic defects in the differential diagnosis of unexplained intestinal obstruction, particularly in elderly patients.

CONCLUSION

Congenital TMIH should be considered in the differential diagnosis of patients with unexplained bowel obstruction, especially when the clinical picture is atypical. Early diagnosis with imaging and surgical repair leads to favorable outcomes, as demonstrated in this case.

Laparoscopic repair of a strangulated internal hernia through the hepatogastric ligament

Internal hernias are a rare cause of small bowel obstruction, but they can lead to significant morbidity and mortality if left untreated, particularly in cases of strangulation. Herniation through the hepatogastric ligament, a component of the lesser omentum, is an exceedingly rare subtype. This report presents the case of a 44-year-old male who presented with worsening epigastric pain and was diagnosed with a strangulated internal hernia. Initial imaging with computed tomography (CT) suggested a closed-loop small bowel obstruction, with presumed herniation through the foramen of Winslow. Intraoperatively, the hernia was found to involve the hepatogastric ligament, a defect that was successfully repaired laparoscopically. This case highlights the pivotal role of CT imaging in the initial evaluation of internal hernias and the value of laparoscopy as both a diagnostic and therapeutic tool.

Risk factors of symptomatic internal hernias after left hemicolectomy: a multicenter retrospective study

BACKGROUND

Mesenteric-related internal hernia after left hemicolectomy is rare. However, it can cause serious consequences, including upper gastrointestinal obstruction and acute intestinal necrosis. This study aimed to explore the potential risk factors of symptomatic internal hernia (SIH) after a left hemicolectomy.

MATERIALS AND METHODS

We retrospectively reviewed the data of patients who underwent a left hemicolectomy at 10 tertiary hospitals between January 2018 and June 2024. Their baseline information, surgical procedures, and early postoperative complications (within 3 months after surgery) were recorded and analyzed.

RESULTS

Overall, 468 patients were included in this study, the majority of patients underwent laparoscopic surgery (76.9%). SIH was detected using postoperative imaging (computed tomography/upper gastrointestinal contrast). Six patients (1.28%) developed SIH (SIH group) and underwent re-operation. Compared with the 462 patients who did not develop SIH (non-SIH group) (with comparable baseline data between groups), the SIH group did not undergo surgery to close the mesenteric defect (0 vs. 56.1%; p = 0.008) and had longer durations of postoperative hospital stay (50.5 ± 37.1 days vs. 14.6 ± 6.4 days; p < 0.001). Relative to the patients without mesenteric defect closure, those who had closure of the mesenteric defects did not have significantly increased duration of surgery (β = - 0.40, 95% CI = - 12.60 to 11.81, p = 0.949) or incidence of postoperative complications other than SIH (β = 0.79, 95% CI = 0.43 to 1.45, p = 0.443).

CONCLUSION

The risk of SIH after left hemicolectomy may increase if closure of the mesenteric defect is not performed. We recommend appropriate management of the mesenteric defect after left hemicolectomy to prevent SIH.

Internal hernia as a rare cause of small bowel obstruction: An insight from 13 years of experience

BACKGROUND

Internal hernia (IH) is a rare culprit of small bowel obstruction (SBO) with an incidence of < 1%. It poses a considerable diagnostic challenge requiring a high index of suspicion to prevent misdiagnosis, improper treatment, and subsequent morbidity and mortality.

AIM

To determine the clinico-demographic profile, radiological and operative findings, and postoperative course of patients with IH and its association with SBO.

METHODS

Medical records of 586 patients with features of SBO presenting at a tertiary care centre at Lucknow, India between September 2010 and August 2023 were reviewed.

RESULTS

Out of 586 patients, 7 (1.2%) were diagnosed with IH. Among these, 4 had congenital IH and 3 had acquired IH. The male-to-female ratio was 4:3. The median age at presentation was 32 years. Contrast-enhanced computed tomography (CECT) was the most reliable investigation for preoperative identification, demonstrating mesenteric whirling and clumped-up bowel loops. Left paraduodenal hernia and transmesenteric hernia occurred with an equal frequency (approximately 43% each). Intraoperatively, one patient was found to have bowel ischemia and one had associated malrotation of gut. During follow-up, no recurrences were reported.

CONCLUSION

IH, being a rare cause, must be considered as a differential diagnosis for SBO, especially in young patients in their 30s or with unexplained abdominal pain or discomfort post-surgery. A rapid imaging evaluation, preferably with CECT, is necessary to aid in an early diagnosis and prompt intervention, thereby reducing financial burden related to unnecessary investigations and preventing the morbidity and mortality associated with closed-loop obstruction and strangulation of the bowel.

Diverse Presentations of Congenital Internal Hernias in Children with Review of Literature

Congenital internal hernia is a rare cause of intestinal obstruction where bowel herniates through congenital mesenteric defects or into the paraduodenal spaces. There is significant diversity in presentation and intraoperative findings among the various types of internal hernia. Here, we are presenting four cases of internal hernia with varied presentations.

Left Para-duodenal hernia with distal bowel ischemia: An unusual presentation of the internal hernia: A case report and literature review

Internal hernias, including Left para duodenal Hernias (LPDH), are rare and challenging to diagnose due to their nonspecific symptoms and complex anatomical presentation. This report presents a unique case of a 29-year-old female with preoperatively diagnosed uncomplicated LPDH, complicated by distal bowel ischemia-a manifestation not extensively documented in existing literature. Initial imaging revealed dilated jejunal loops indicative of LPDH, with subsequent contrast-enhanced computed tomography (CECT) showing ischemic changes in bowel segments distal to the hernia. Surgical exploration confirmed 120 cm of gangrenous bowel, necessitating resection and jejunostomy. This case highlights the diagnostic and therapeutic challenges of LPDH and highlights the crucial role of advanced imaging in identifying associated complications.

Transomental hernia resulting in a closed loop small bowel obstruction: delayed presentation following paediatric blunt abdominal trauma

While internal hernias are rare in the paediatric population, it should be considered as a cause for an acute abdomen following blunt trauma. Internal hernias represent a surgical emergency that requires prompt recognition due to the high risk of strangulation and ischaemia of affected bowel loops. The case of a transomental hernia (TOH) is described in a young girl. She re-presented to the emergency department with acute abdominal pain 3 weeks following a motor vehicle accident where she was a restrained passenger. A computed tomography scan demonstrated a closed loop small bowel obstruction with features of ischaemia, which was likely secondary to an internal hernia. Urgent surgical intervention revealed a TOH containing ischaemic but viable loops of small bowel. Laparoscopic reduction of the hernia was successful, and the patient made a good recovery.

Diagnostic challenges of hiatal hernia Type IV: An imaging perspective

Type IV hiatal hernia is a mixed type of hiatal hernia characterized by the herniation of visceral organs other than the stomach into the mediastinum. It is the least common type of hiatal hernia. We report a case of a 4-month-old male infant who presented with shortness of breath and persistent vomiting. Initial chest X-ray suggested a mediastinal mass, but further evaluation with chest computed tomography (CT) scan revealed herniation of the stomach and duodenum through the hiatal oesophagus into the thoracic cavity. Radiological imaging was crucial in confirming the diagnosis of hiatal hernia.

Strangulated left para-duodenal hernia: A case report and review of literature

Internal hernias are a rare entity with an incidence of 0.2%-0.9% among all hernias. Patients may present with a wide spectrum of symptoms, but strangulated para-duodenal hernias are relatively rare. We present a case of a 24-year-old male who presented with severe abdominal pain. He was diagnosed with a left para-duodenal hernia through contrast-enhanced computed tomography of the abdomen and pelvis. He underwent exploratory laparotomy followed by the resection of strangulated ileal loops with ileo-ileal anastomosis. Emergency surgery is the mainstay of management, and the approach to surgery, open vs. laparoscopic, depends on the surgeon's expertise and available infrastructure. The mortality rate is high if hernias are complicated by incarceration, strangulation, or obstruction.

Small Bowel Obstruction Due to Concurrent Petersen's and Pouch of Douglas Hernias in a Patient With a Complex Surgical History: A Rare Surgical Case

Internal hernias are a rare but significant cause of small bowel obstruction, particularly in patients with a history of abdominal surgery such as Roux-en-Y gastric bypass (RYGB). Although Petersen's hernia is the most commonly encountered internal hernia in these patients, herniation into the Pouch of Douglas is an exceedingly rare occurrence. This report describes the case of a 77-year-old female with a complex surgical history, including RYGB and hysterectomy, who presented with several months of postprandial abdominal pain, nausea, and vomiting. A computed tomography (CT) scan initially suggested mild bowel distention without clear evidence of obstruction. However, due to the inability to tolerate oral intake, a follow-up CT scan was performed and revealed dilated loops of the small bowel, prompting surgical intervention. Intraoperatively, two internal hernias were identified: one at Petersen's defect and another in the Pouch of Douglas, the latter being the cause of the obstruction. Both hernias were reduced, and the peritoneal defect in the Pouch of Douglas was closed using sutures. The patient recovered without complications and was discharged to rehabilitation. This case demonstrates the importance of considering internal hernias, including rare types, in post-surgical patients presenting with nonspecific symptoms of bowel obstruction. Early diagnosis and timely surgical management are crucial to prevent complications such as bowel ischemia and to ensure optimal outcomes. Closing peritoneal defects during hernia repairs is essential to minimize the risk of recurrence. This case contributes to the limited literature on internal hernias involving the Pouch of Douglas and emphasizes the need for thorough diagnostic evaluation in complex clinical scenarios.

Robotic repair of a right paraduodenal hernia: a clinical presentation and management

Paraduodenal hernias are rare internal hernias in which the small intestine becomes trapped behind the mesentery of the colon. These hernias can lead to bowel obstruction and ischaemia, making early diagnosis and intervention crucial. Patients often exhibit non-specific symptoms, highlighting the importance of using CT imaging for diagnosis. Prompt surgical correction is necessary to prevent severe complications such as bowel ischaemia or necrosis. While open and laparoscopic approaches are well-established, there is limited evidence on the robotic repair of paraduodenal hernias as a minimally invasive technique. This case report describes a man in his early 30s who presented with persistent abdominal pain and vomiting. Imaging revealed a right paraduodenal hernia with characteristic CT findings showing clustered jejunal loops and abnormal mesenteric rotation. The patient successfully underwent robotic hernia repair, which involved identifying and reducing the hernia sac and securing the defect with polypropylene sutures. The postoperative recovery was complication-free. This case underscores the effectiveness of robotic techniques in managing this rare presentation and emphasises the importance of timely diagnosis and intervention.

Successful laparoscopic management of strangulated left paraduodenal hernia: A case report and review of minimally invasive approaches

INTRODUCTION

Paraduodenal hernias are rare congenital anomalies that can lead to acute bowel obstruction and strangulation. Laparoscopic management of these complex cases in emergency settings remains challenging, particularly when bowel ischemia is present.

CASE PRESENTATION

We report a case of a 56-year-old woman presenting with acute small bowel obstruction due to a strangulated left paraduodenal hernia. Emergency laparoscopic surgery revealed ischemic bowel segments within the hernia sac. We utilized indocyanine green (ICG) fluorescence imaging to assess bowel perfusion intraoperatively, guiding our decision for bowel resection. The procedure involved hernia reduction, resection of non-viable bowel, and primary anastomosis, followed by hernia defect closure. Despite encountering a small bowel injury during reduction, we successfully completed the procedure laparoscopically.

DISCUSSION

This case demonstrates the feasibility of laparoscopic management for complicated paraduodenal hernias with bowel strangulation in emergency settings. The use of ICG imaging for real-time perfusion assessment represented a novel application in this context, aiding in the precise identification of ischemic bowel segments requiring resection.

CONCLUSION

Laparoscopic repair of strangulated paraduodenal hernias is feasible and effective, even in emergency scenarios. The integration of advanced imaging techniques like ICG fluorescence may enhance intraoperative decision-making, particularly in assessing bowel viability. This approach potentially reduces the extent of bowel resection and improves outcomes in these complex cases.

A Case of Pediatric Internal Hernia Heralded by Constipation

Meckel's diverticulum (MD) is the most common gastrointestinal congenital anomaly of the small intestine. A small subset of patients with MD develops a mesodiverticular band (MDB), creating a snare-like opening and the potential for internal hernias (IHs). IHs are a known possible cause of small bowel obstructions and are most common in adults post bariatric surgery. Herein, we present an atypical case of pediatric internal hernia caused by an MDB. A six-year-old male child with chronic constipation presented with one week of abdominal pain and one day of non-bloody, non-bilious emesis, decreased appetite, and normal non-bloody bowel movements. The patient appeared uncomfortable with mild abdominal right upper quadrant tenderness. Laboratory results were remarkable for mild leukocytosis and hyperkalemia. Computed tomography was concerning for IH. General surgery performed a diagnostic laparotomy, revealing an IH caused by an MDB. The MDB was released, and the patient had an uneventful recovery. Pediatric IHs are very rare. Surgery represents the primary management of symptomatic MDBs, as it allows for the hernia to be released before complications occur, such as bowel necrosis or gangrene. This case highlights the importance of considering IH caused by MDB in pediatric patients presenting with constipation.

Don't be thrown for a loop: a review of internal hernias for the abdominal imager

Internal hernias are herniations of abdominal viscera, usually small bowel, through congenital or acquired openings of the peritoneum or mesentery. Congenital hernias may involve anatomic fossae such as the epiploic foramen as well as those related to abnormal peritoneal or mesenteric defects; these include left and right paraduodenal, transomental, transmesenteric, pericecal and broad ligament hernias. Acquired hernias are due to defects in the mesentery or peritoneum, usually resulting from prior surgeries, and include those associated with Roux-en-Y surgery as well as colorectal cancer resections. Internal hernias account for 5.8% of small obstructions. Obstructed internal hernias are considered surgical emergencies due to the high risk of bowel strangulation. This review summarizes the various types of congenital and acquired internal hernias, their relevant anatomy, embryology, associated surgical history and imaging appearance. We will also discuss a location-based approach to identifying internal hernias on CT, as well as complications and relevant signs, of which abdominal imagers should be vigilant.

Transmesenteric internal hernia: an unexpected adverse event induced by colonoscopy

Transmesenteric internal hernia is an uncommon cause of small bowel obstruction that occurs when small bowel loops protrude through a mesenteric defect into the abdominal cavity. Herein, we present an unexpected case of colonoscopy-induced transmesenteric internal hernia. An 81-year-old male patient presenting with intermittent hematochezia and constipation had undergone a laparoscopic left nephrectomy for ureteral cancer. A colonoscopy was performed to identify the etiology of his symptoms. He complained of severe abdominal pain 2 h after the examination despite uneventful endoscopic procedures, including cold snare polypectomy. Contrast-enhanced computed tomography revealed a strangulated small bowel obstruction with a closed-loop formation outside the descending colon. The small bowel loop was incarcerated into the left retroperitoneal space. Emergency laparotomy detected small bowel loops that prolapsed into the nephrectomy pedicle via a descending mesenteric defect, developed during the laparoscopic left nephrectomy. The incarcerated small bowel was detached from the hernia and returned to its normal position, and the mesenteric defect was closed. He demonstrated an uneventful postoperative course, with no internal hernia recurrence after discharge. This case indicates the risk of transmesenteric internal hernia through inadvertently created mesenteric defects should be borne in mind, especially when performing colonoscopies in patients who underwent laparoscopic nephrectomies.

Unusual causes of Small bowel obstruction: a review of the literature and revisited cross-sectional imaging checklist

Intestinal obstruction is a common surgical emergency with high morbidity and mortality. Patients presenting with features of small bowel obstruction need urgent evaluation to avoid complications such as bowel gangrene, perforation, or peritonitis. Imaging is necessary in most cases of suspected bowel obstruction, to take an appropriate decision, for apt patient management. Among the common causes of small bowel obstruction, adhesions, external herniae, malignancies, and Crohn's disease top the chart. Imaging helps in determining the presence of obstruction, the severity of obstruction, transition point, cause of obstruction, and associated complications such as strangulation, bowel gangrene, and peritonitis. This review is based on the cases with unusual causes of bowel obstruction encountered during our routine practice and also on the extensive literature search through the standard textbooks and electronic databases. Through this review we want our readers to have sound knowledge of the imaging characteristics of the uncommon yet important causes of bowel obstruction. We have also revisited and structured a checklist to simplify the approach while reporting a suspected case of small bowel obstruction. Imaging plays a key role in the diagnosis of small bowel obstruction and in determining the cause and associated complications. Apart from the common causes of small bowel obstruction, we should also be aware of the uncommon causes of small bowel obstruction and their imaging characteristics to make an accurate diagnosis and for apt patient management.

An incarcerated paraduodenal hernia of a malrotated gut in a 26-year-old man

Introduction and importance: Paraduodenal hernias (PDHs) are congenital internal hernias. Overall, internal hernias are between 0.2 % and 0.9 %, while 53 % of these statistics are for PDH. There are left and right types of PDHs.

CASE PRESENTATION

An otherwise healthy 26-year-old man was presented with a sudden-onset epigastric and right upper quadrant abdominal pain. Abdominopelvic double contrasted CT scan revealed multiple dilated proximal-mid small bowel loops in the portal venous phase consistent with small bowel obstruction, suggesting concomitant bowel malrotation with internal paraduodenal hernia. The patient with the pre-operative diagnosis of small bowel obstruction due to volvulus was scheduled for emergency surgery. He was four weeks complication-free in his regular follow-up.

CLINICAL DISCUSSION

In 1857, Treitz first described PDH as a phenomenon when the primitive midgut in embryonic life abnormally rotates and causes mesocolic hernia. The location of the duodenal recess is the origin point for describing the hernia; thus, the jejunum is the most common herniating viscus. However, the stomach, small intestine, and sometimes the colon usually consist of the contents of the hernia.

CONCLUSION

In the absence of surgical history, abdominal wall hernia, and intra-abdominal inflammatory disease, in case of repeated abdominal pain or intestinal obstruction, and if no other causes are found, the possibility of a PDH should be kept in mind.

A Rare Presentation of a Transverse Mesocolic Internal Hernia: A Case Report

Internal hernias (IHs) are a rare but potentially life-threatening cause of bowel obstruction, with a high morbidity and mortality rate if not promptly diagnosed and treated. This case report highlights the clinical course of a 75-year-old female who developed a transverse mesocolic internal hernia, a subtype of transmesenteric hernia (TH), following a Hartmann reversal procedure. The patient presented to the emergency department (ED) with a sudden onset of severe, diffuse abdominal pain. Her medical history was significant for systemic lupus erythematosus, pulmonary fibrosis, multiple pulmonary embolisms, and a recent Hartmann reversal procedure the month prior. Initial imaging suggested postoperative ileus, but the patient's symptoms persisted despite conservative management. Subsequent imaging raised suspicion of an internal hernia, and on hospital day 6, an urgent diagnostic laparoscopy revealed a herniated segment of the small bowel through a defect in the transverse mesocolon with herniation into the lesser sac. The herniated bowel was successfully reduced, and the defect was repaired. The patient had an uneventful recovery and was discharged in stable condition. Transmesenteric hernias, though more common in the pediatric population, can occur in adults, particularly following abdominal surgery. Diagnosis can be challenging due to variable symptoms and imaging findings. However, prompt recognition and surgical intervention are crucial to prevent complications such as bowel ischemia and strangulation. This case underscores the importance of considering internal hernias in the differential diagnosis of small bowel obstruction (SBO), especially in patients with a history of recent abdominal surgery. Early diagnosis and timely surgical management are essential for a favorable outcome.

The intra-abdominal zebra, paraduodenal hernias resulting in small bowel obstructions: a case series

Paraduodenal hernias are a rare but important clinical entity, as their presentation can be life-threatening if not properly diagnosed and managed appropriately. Additionally, this entity is defined by a unique and complex congenital anatomical abnormality which dictates a specific treatment algorithm. Here we present the cases of three patients from our clinical experience who all presented with either acute or chronic small bowel obstructions secondary to paraduodenal hernias. Two were left-sided paraduoenal hernias and one was right-sided. All three patients were successfully managed with surgical intervention. An appreciation of paraduodenal hernias, including the defining anatomy and methods of surgical management, is important for the general surgeon.

Laparoscopic left paraduodenal hernia repair: A case report

Paraduodenal hernias (PDH) pose a diagnostic challenge due to their varied presentations and rarity. We report a rare case report illustrating the clinical course, diagnostic approach, and management of PDH in a 19-year-old female patient with a history of neonatal laparotomy for intestinal atresia. The patient initially presented with chronic, diffuse abdominal pain, which had progressively worsened over 2 years. Physical examination revealed no palpable mass, with normal bowel sounds and vital signs. Imaging studies, including computed tomography of the abdomen, demonstrated protrusion of small bowel loops in the left upper abdominal quadrant consistent with a left paraduodenal hernia. Following laparoscopic exploration, a large defect was identified, and successful repair was performed, resulting in resolution of symptoms and a smooth postoperative recovery. Our case highlights the importance of maintaining a high index of suspicion for PDH in patients with chronic abdominal pain, particularly those with a history of abdominal surgeries. Prompt diagnosis and timely surgical intervention, preferably laparoscopic, can lead to favorable outcomes and improved quality of life for affected individuals.

Ultrasound imaging of bowel obstruction in infants and children

We review the etiologies of bowel obstruction in infants and children that can be identified on ultrasound (US) including perforated appendicitis, intussusception, foreign body ingestion, colonic volvulus, intra-abdominal mass lesions, internal hernia, and stricturing inflammatory bowel disease. US can potentially identify the cause of bowel obstruction in these age groups, without the need for additional cross-sectional imaging, and can aid in patient management including interventional and surgical planning. Hence, it is important to be familiar with the sonographic imaging findings of bowel obstruction in infants and children.

Caecal Volvulus in a Foramen of Winslow Hernia Masquerading as Biliary Colic

Internal hernias account for a minority of cases of intestinal obstruction. Within this group, internal hernias through the foramen of Winslow (FW) are an even rarer subcategory with a paucity of cases reported in the literature. We present a case of a 48-year-old female presenting with right upper quadrant pain akin to biliary colic with sonographic evidence of cholelithiasis. Her symptoms swiftly worsened, and she re-presented with symptoms of bowel obstruction. She was subsequently found to have a caecal volvulus herniating through the FW on computed tomography (CT). She underwent an emergency laparotomy to reduce the hernia and prevent further recurrence, which highlighted the importance of a comprehensive history and the increasing role of cross-sectional imaging in emergency surgery.

Internal Herniation Causing Double Obstruction of the Small Bowel and Urinary Tract: A Rare Case Presentation

Small bowel obstruction is one of the most common urgent surgical conditions, caused by a variety of factors, with adhesions, malignancies, and hernias, internal and external, being the most common. Many types of internal hernias have been described in the literature; however, internal hernia caused by the ureter as a secondary complication of ureteroplasty is rare and only a few cases have been reported worldwide. This presentation discusses an interesting case of small bowel obstruction accompanied by obstruction of the urinary tract due to an internal hernia caused by the ureter. A 58-year-old female presented to the emergency department (ED) with acute pain in the abdominal and right lumbar region. Her surgical history includes hysterectomy, right ureter injury, and ureteroplasty performed 10 years ago. Clinical examination showed tenderness in the lower abdomen, positive Giordano's sign on the right, and metallic bowel sounds. A computer tomography scan revealed right-sided hydronephrosis, absence of excretion in the right urinary tract, and dilated loops of the small intestine. An exploratory laparoscopy revealed a small bowel loop strangulated by the ureter, followed by laparotomy, resection of a segment of the ileum, oblique anastomosis, and reimplantation of the right ureter. The patient was discharged eight days postoperatively without any complications. This case underscores the significance of surgical history in order to recognize even rarer causes of small bowel obstruction.

Mesocolic hernia, a case series

INTRODUCTION AND IMPORTANCE

Paraduodenal hernias are difficult to diagnose due to their unusual presentation. Herein, five new cases are added to the literature.

CASE PRESENTATION

Four male and one female child complained of paraduodenal hernias, two on the right side and three on the left side. The intestinal part that herniated inside the hernia sac was also malrotated in four patients. One patient had Meckel's diverticulum with a herniated intestine. One infant had extrahepatic biliary disease, a single atrium, polysplenia, intestinal malrotation, and a left paraduodenal hernia. Exploratory labarotomy was done for reduction of the intestine, reorientation, and repair of hernia orifices.

CLINICAL DISCUSSION

Paraduodenal hernia is a component of malrotation. Cautious dissection of the hernia orifice is required to keep away from injuries to the inferior mesenteric vein or left colic artery in the course of the restoration of the left paraduodenal hernia. Also, the superior mesenteric vessels may be injured in the course of the restoration of the right paraduodenal hernia.

CONCLUSION

There is a correlation between the occurrence of PDH with malrotation. The diagnosis of malrotation can be made with an ultrasound abdomen; however, it is true that ultrasound cannot make a confirmed diagnosis in all patients. Once the diagnosis of a mesocolic hernia has occurred, surgical repair is mandatory by closure of the defect.

Radiographic Features of a Strangulated Transomental Hernia

This is a case report of an 82-year-old male who presented with intractable and diffuse abdominal pain and had a computed tomography (CT) abdomen showing a closed loop obstruction in the right hemiabdomen with anteromedial displacement of the cecum and ascending colon. Exploratory laparotomy revealed a gangrenous segment of the ileum strangulated by a transomental hernia in the right lower quadrant. The nonviable bowel was resected, and the healthy bowel segments were anastomosed. It is important to correlate the clinical signs of bowel obstruction with radiographic findings of internal hernia to expedite surgical intervention and prevent complications of bowel ischemia.

Cecal bascule presenting as internal hernia

Cecal bascule, a rare subtype of cecal volvulus, presents diagnostic and management challenges. We report a case of cecal bascule presenting as an internal hernia in a 68-year-old male with no surgical history. Computed tomography revealed two areas of mesenteric swirling and a displaced cecum. Prompt surgical intervention included laparoscopic exploration, resection of a necrotic adhesive band, and cecopexy. This case is noteworthy because of the absence of predisposing factors like prior surgeries or inflammatory conditions. Management options for cecal bascule include resection and cecopexy, tailored to individual patient factors. Awareness among healthcare providers is crucial for the timely recognition and appropriate management of such cases. Further research is needed to refine management strategies and improve outcomes for these rare but potentially life-threatening conditions.

Right paraduodenal hernia presenting with strangulated obstruction with intestinal malrotation: a case report

A paraduodenal hernia is a rare cause of an internal hernia that may require massive bowel resection; prompt diagnosis and surgical treatment are essential. In cases of malrotation, strangulation may occur both inside and outside the hernial sac. Strangulation outside the hernial sac makes the preoperative diagnosis more difficult. Herein, we report a patient with a right paraduodenal hernia, intestinal malrotation, and strangulation outside the hernia. An 86-year-old woman was admitted to our hospital with abdominal pain. Enhanced computed tomography showed a closed-loop obstruction of the hypo-enhancing small bowel and absence of a horizontal duodenal leg. The patient underwent an emergency laparotomy and was diagnosed with strangulated bowel obstruction due to a right paraduodenal hernia and malrotation. The patient underwent resection of the ischemic ileum, closure of the hernial orifice, and repositioning of the intestine. The postoperative course was uneventful. The patient reported no abdominal discomfort after 7 months of follow-up.

Herniation of the Right Colon, From the Cecum to the Hepatic Flexure, Through the Foramen of Winslow: A Case Report

Herniation of bowel contents between the peritoneal cavity proper and the omental bursa, through the foramen of Winslow, can present diagnostic challenges that can potentially delay necessary surgical intervention. This case describes a 49-year-old female with a past medical history of hiatal hernia and biliary dyskinesia who presented to the emergency department with severe epigastric and right lower quadrant abdominal pain one day after a reported gastrointestinal illness of unknown etiology. Initial emergency department workup demonstrated an elevated white blood cell count without lactic acidosis. Computed tomography imaging was interpreted as gastric distension with volvulus around the mesentery and second portion of the duodenum. Intraoperatively, the entirety of the right colon was noted to have passed through the foramen of Winslow into the lesser sac. This led to twisting of the mesocolon causing compression of the duodenum and a gastric outlet obstruction. After surgical reduction of the herniation, the patient noted great improvement in pain and other symptoms.

Two cases of strangulated bowel obstruction due to exposed vessel and nerve after laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer

BACKGROUND

The majority of small bowel obstructions (SBO) are caused by adhesion due to abdominal surgery. Internal hernias, a very rare cause of SBO, can arise from exposed blood vessels and nerves during pelvic lymphadenectomy (PL). In this report, we present two cases of SBO following laparoscopic and robot-assisted lateral lymph node dissection (LLND) for rectal cancer, one case each, of which obstructions were attributed to the exposure of blood vessels and nerves during the procedures.

CASE PRESENTATION

Case 1: A 68-year-old man underwent laparoscopic perineal rectal amputation and LLND for rectal cancer. Four years and three months after surgery, he visited to the emergency room with a chief complaint of left groin pain. Computed tomography (CT) revealed a closed-loop in the left pelvic cavity. We performed an open surgery to find that the small intestine was fitted into the gap between the left obturator nerve and the left pelvic wall, which was exposed by LLND. The intestine was not resected because coloration and peristalsis of the intestine improved after the hernia was released. The obturator nerve was preserved. Case 2: A 57-year-old man underwent a robot-assisted rectal amputation with LLND for rectal cancer. Eight months after surgery, he presented to the emergency room with a complaint of abdominal pain. CT revealed a closed-loop in the right pelvic cavity, and he underwent a laparoscopic surgery with a diagnosis of strangulated SBO. The small intestine was strangulated by an internal hernia caused by the right umbilical arterial cord, which was exposed by LLND. The incarcerated small intestine was released from the gap between the umbilical arterial cord and the pelvic wall. No bowel resection was performed. The umbilical arterial cord causing the internal hernia was resected.

CONCLUSION

Although strangulated SBO due to an exposed intestinal cord after PL has been a rare condition to date, it is crucial for surgeons to keep this condition in mind.

A late presentation of a left paraduodenal hernia in an elderly patient admitted in emergency: A case report

Small bowel internal hernias (IHs), a rare cause of small bowel occlusion (SBO) and small bowel strangulation, while more commonly seen in young adults, can also affect elderly patients and pose a significant diagnostic challenge due to their nonspecific symptoms. In most cases, laparotomy was used to diagnose IHs. However, multidetector computed tomography (MDCT) is usually the best imaging tool to use in the emergency setting for the diagnosis of IHs. An 83-year-old man was admitted to emergency with acute abdominal pain and a coffee-ground vomitus. The abdominal MDCT showed a clustered-like appearance of proximal jejunal loops at the level of the Treitz ligament with the absence of transit of the medium water-soluble iodine oral contrast agent (Gastrografin). Mesenteric edema was also present with initial suffering of the intestinal wall. A left paraduodenal hernia (LPDH) with strangulation was suspected following the radiological report. The emergency laparotomy revealed about 20 cm of proximal jejunal loops herniated through a 3 cm wide hernia orifice (HO) along the Treitz ligament, at the level of Landzert fossa, located in the confluence of the descending mesocolon, posterior to the inferior mesenteric vein (IMV) and confirming the LPDH. The patient was discharged in good condition some days later. IHs do not have sufficient coverage in literature, especially in cases regarding elderly patients, however, they can be a cause of SBO in people older than 80 years of age. Radiologists and surgeons should be aware of the anatomical aspects of the IHs.

Congenital mesocolic hernia-a case report

Internal hernias are defined as protrusions of viscera through congenital or acquired aperture within the peritoneal cavity without an exit from the abdomen. The entity is broadly diversified with a wide variety of forms and severity of symptoms. A 10-day-old, full-term infant with poor feeding, bilious vomiting, and faecal retention for 3 days presented at our hospital. In the abdominal ultrasound, a whirl-pool sign was detected and laparotomy indicated. Intraoperatively, a malrotation of the small bowel with herniation of the jejunum into a mesocolic hernia was detected.

Retrorectal Hernia: A Rare Cause of Constipation Diagnosed on Magnetic Resonance (MR) Defecography

Retrorectal herniation of the sigmoid colon is a rare condition characterized by the protrusion of a segment of the colon into the pre-sacral space and posterior to the rectum. This herniation occurs through a defect in the peritoneum, which may have developed secondary to congenital mechanisms, surgery, trauma, or inflammatory processes. Here, a case of retrorectal herniation of the sigmoid colon in an elderly female patient presenting with constipation is reported, with a review of the literature.

[A case of abdominal internal hernia through the foramen of Winslow in a pediatric emergency department]

Abdominal internal hernia is a rare cause of intestinal obstruction in pediatric emergency departments, being the herniation through the foramen of Winslow an exceptional entity (less than 0.5% of the herniae). We report the case of a 15-year-old adolescent male without previous surgical interventions who presented with abdominal pain and vomiting; computed tomography scans showed intestinal obstruction due to an internal hernia through the foramen of Winslow. To reduce the herniated ileum, the patient required surgical intervention with diagnostic laparoscopy, which, due to bad visualization, was changed to supraumbilical midline laparotomy. There was no need to resect the affected ileum as it appeared healthy. We did not perform a preventive technique to reduce the risk of recurrence. Postoperative pelvic collection was conservatively managed with antibiotics. The patient undergoes regular follow-up in the pediatric surgery department.

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.

Internal Herniation of the Transverse Colon and Stricture of the Gastric Body: A Case Report

Internal herniation is a protrusion of the bowel limited to the abdominal cavity. This pathology is rare and difficult to diagnose due to a wide array of symptoms that may manifest. Internal hernias have the potential to affect surrounding organs such as the stomach and adjacent bowel due to the compressive force of the protruding bowel. The effects of internal herniation commonly present in one of two ways: acute obstruction which requires emergent intervention and subacute, vague symptoms that are difficult to diagnose. This case presents the findings of a post-mortem dissection of a 92-year-old willed body donor. Dissection of the abdominal cavity revealed a large internal hernia of the transverse colon that communicated superiorly posterior to the stomach. As a result of the hernia, the stomach in this patient had a stricture of the gastric body. We assert that this stricture was formed over an extended period of time due to the lack of diagnosis and treatment of the internal hernia.

Congenital Transmesenteric Hernia With Closed-Loop Small Bowel Obstruction and Intestinal Gangrene in an Adult

Internal hernias (IHs) are defined as the protrusion of the intestine through an aperture in the peritoneal ligament, mesentery, or the omentum, without traversing the fascial planes and leading to encapsulation of the protruded intestine within another compartment of an otherwise intact abdominal cavity. Internal hernias can be acquired or congenital. Congenital internal hernias resulting in small bowel obstruction are extremely rare, even more so in adults, occurring usually due to embryological or developmental defects, often undiagnosed, and requiring a high index of clinical suspicion. We report a rare case of a 22-year-old young adult with transmesenteric hernia of distal ileum through a congenital distal ileal mesenteric defect resulting in closed-loop small bowel obstruction and distal ileal gangrene, managed with resection and end-ileostomy, followed by stoma reversal one month later. It requires a high index of suspicion and remains a surgical emergency due to its predilection for intestinal gangrene and small bowel obstruction, with a high mortality rate due to delayed presentation and diagnosis.

A surgical case report of an epiploic hernia - A mobile right colon herniating through the foramen of Winslow

INTRODUCTION

An Epiploic Hernia is an extremely rare type of abdominal hernia with <0.1 % incidence where the bowel or other intra-abdominal contents herniate through the Foramen of Winslow. A case of an Epiploic hernia in a middle-aged female is presented here.

PRESENTATION OF CASE

A woman in her 60s was admitted to a tertiary level hospital with severe right sided intermittent upper abdominal pain associated with nausea, bloating and constipation. The symptoms were thought to be due to biliary colic and managed conservatively. Since the symptoms persisted and a computed tomography scan of abdomen was organized. CT scan showed that the caecum was in the upper left quadrant. A laparoscopy was performed and demonstrated that her right colon was mobile herniating through the Foramen of Winslow into the lesser sac. The hernia was reduced, and the bowel was viable. The patient was discharged with no complications.

DISCUSSION

There have been case reports of small bowel as the content of the hernia with lesser occurrences of caecum, ascending colon, transverse colon, gall bladder, omentum, or Meckel's diverticulum. A caecal herniation through the Foramen of Winslow is reported only with an incidence of 0.02 %. <10 % of these Epiploic hernias are diagnosed preoperatively making it a potentially life-threatening condition if not treated promptly due to high risk of bowel strangulation and mortality of up to 50 %.

CONCLUSION

A high index of suspicion is needed for the diagnosis of this internal hernia and radiological investigation is fundamental in making this diagnosis for allowing prompt surgical treatment.

[Strangulated hernia of the foramen of Winslow complicated by acute colonic obstruction]

Internal hernias, in particular, hernia of the foramen of Winslow, are rare and occur in typical sites. Laparotomy is common in these cases while laparoscopic surgery is rarely used in such urgent cases. However, modern diagnosis and treatment including computed tomography and laparoscopy allowing minimally invasive interventions are not an exception for patients with hernia of the foramen of Winslow. This approach is effective for this problem and prevents adverse outcomes of disease.

When the Gut Took a Wrong Turn to the Right: A Case Report of a Rare Complication of Closed Loop Small Bowel Obstruction With Small Bowel Volvulus in a Right Paraduodenal Hernia With Midgut Malrotation

Internal hernias constitute 5.8% of all small bowel obstructions. The right paraduodenal hernia is a less common subtype of the paraduodenal hernia. Lack of specific signs and symptoms precludes its clinical diagnosis, which emphasizes the need for computed tomography in diagnosis. We present a case of a 24-year-old male patient with a right paraduodenal hernia and midgut malrotation causing closed loop small bowel obstruction and small bowel volvulus within the hernial sac who underwent laparoscopy-assisted reduction of hernia and adhesiolysis with closure of the peritoneal defect. Since the right paraduodenal hernia is associated with gut malrotation, risk of strangulation, closed-loop obstruction, and rarely volvulus, these patients need prompt radiological diagnosis and surgical intervention.

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.

Petersen's Hernia After Roux-en-Y Gastric Bypass: A Case Report

Internal hernia (IH) is the protrusion of abdominal contents, mostly small bowel loops, through a defect in the peritoneum or mesentery. Petersen's hernia is a type of internal hernia, in which part of the intestinal loop protrudes through a defect between small bowel limbs, transverse mesocolon, and retroperitoneum. It has been reported in individuals undergoing gastrojejunostomy (GJ), especially following bariatric surgeries. Because of the expanding popularity of these surgical treatments, the total incidence of internal hernias has recently increased. The laparoscopic Roux-en-Y gastric bypass (RYGB) has been proven to be a safe and successful alternative to the classic open RYGB. Although the absence of postoperative adhesions is one advantage of minimally invasive surgery, it facilitates the occurrence of internal hernia with reported rates of 5% three months to three years following surgery. Clinical findings are vague and can vary from mild to severe abdominal pain that can be accompanied by vomiting, nausea, and abdominal distention.

Internal hernia through the foramen of Winslow: a rare cause of intestinal obstruction with imminent ischaemia of the caecum

An internal hernia through the foramen of Winslow represents a rare surgical pathology. This report describes a case with incipient caecal ischaemia and discusses current diagnostic and therapeutic approaches. A patient in his early 60s presented at the emergency department with abdominal pain and last bowel movement three days prior. A CT scan of the abdomen suggested an internal hernia into the lesser sac. Intraoperatively, the suspected diagnosis could be confirmed laparoscopically with a twisted mobile caecum herniating through the foramen of Winslow. Due to a suspected ischaemia and laparoscopic frustrated reduction, a right open hemicolectomy was performed. The hernia gap was closed. The postoperative course was uneventful. Despite the rarity of internal hernias in patients without prior abdominal surgery, surgeons should be aware of this entity. The diagnosis can be difficult and sometimes only established intraoperatively. Open surgery is usually required. If the gap is clearly identified, the recommendations tend towards its closure.

Spontaneous lesser omental herniation resolved by laparoscopic surgery: case report and systematic literature review

BACKGROUND

Despite its extremely low incidence, intra-abdominal herniation through the lesser omentum is associated with a high mortality rate and must be recognized early and treated urgently. To overcome a lack of data on the management of this condition, we collected and reviewed all the reported cases of operated lesser omental hernia and presented the case of a patient treated by laparoscopy for an isolated lesser omental hernia.

METHODS

According to PRISMA guidelines and using PubMed, Cochrane Library, and Web of Science, a systematic literature review of cases of lesser omental hernia treated by surgery was performed on February 12, 2023.

RESULTS

Of 482 articles, 30 were included for analysis and only 9 articles presented an isolated hernia through the lesser omentum. Among these, 4 patients were female and the median age was 38. Upper abdominal pain and vomiting were reported in 7 out of 9 patients. The small bowel was responsible for 78% (7/9) of all lesser omental herniations. All of them were treated by laparotomy. In addition, we describe the case of a 65-year-old woman without prior surgical history who was treated by laparoscopy for a spontaneous closed loop hernia through the lesser omentum without any other associated hernias.

CONCLUSION

Mostly associated with prior surgery or trauma, this type of herniation could sometimes occur spontaneously without any sign of peritonitis. Due to the high mortality rate, internal abdominal hernias should always be ruled out with a CT scan in front of patients presenting with persisting acute abdominal pain and no alternative diagnosis.

Midgut volvulus in a pediatric patient with chronic constipation, congenital intestinal malrotation and internal transmesocolic hernia

Congenital intestinal malrotation occurs in 1 of 500 newborns and can predispose patients to intestinal volvulus and internal herniation, putting patients at risk for intestinal ischaemia. A male patient in early childhood with a history of severe constipation presented with acute abdominal pain, progressing rapidly to compensated shock. CT scan was suspicious for small bowel ischaemia and superior mesenteric artery compression. He underwent emergency exploratory laparotomy. Intraoperative findings were significant for partial intestinal malrotation with mobile ascending colon and high-riding caecum, and internal herniation with midgut volvulus of the ascending colon through a mesenteric defect in the proximal transverse colon. Derotation of the volvulus, reduction of the internal hernia, resection of necrotic segments of the bowel and a modified Ladd's procedure were performed. Postoperatively, the patient is total parenteral nutrition (TPN) dependent due to short bowel syndrome. A high index of suspicion with prompt imaging is paramount for paediatric patients with symptoms indicating intestinal obstruction.