internal hernias are rare but there

1. Dr. Asif Mian Ansari
DNB resident
Dept. of General Surgery
Max hospital, Mohali

2.  Hernia
 Protrusion of an organ/part of organ
 Through it’s containing wall

3.  Source of chronic/intermittent abdominal
pain
 33% internal hernias present as SBO
 40% present as strangulation
 Mild digestive symptoms to acute obstructive
features
 Difficult preop diagnosis
 If reducible  silent
 Incidence increased from last decade as more
liver transplant & RYGB surgeries

4.  Protrusion of viscera into a compartment
 Through the peritoneum or mesentery, which
may be:
 Pre existing anatomical structure
 Recess or fossa
 Acquired openings
 Predisposing factors
 Congenital
 Acquired

5.  Paraduodenal 53%
 Pericecal 13%
 Foramen of Winslow
8%
 Transmesenteric 8%
 Intersigmoid 6%
 Supravesical/pelvic 6%
 Retroanastomotic 5%
 Transomental 4%

6. LEFT PD HERNIA
 40% of all (most common)
 Congenital fossa of
Landzert (2%) at DJ
junction behind the IMV
 Chronic postprandial pain
RIGHT PD HERNIA
 13 %
 Congenital fossa of
Waldayer (<1%) behind the
SMA
 Chronic postprandial pain

8. Right Paraduodenal
hernia

9. LEFT PD HERNIA
 Encapsulated cluster of
jejunum in LUQ- barium
study
RIGHT PD HERNIA
 Encapsulated cluster of
bowel loops lateral &
inferior to descending
duodenum- barium study

10. LEFT PD HERNIA
 CT:loops between stomach &
pancreas, behind pancreas or
between transverse colon &
left adrenal gland
RIGHT PD HERNIA
 CT: loops lateral & inferior
to descending duodenum

11.  Management :
 In lines of acute intestinal obstruction
 Naso-gastric drainage
 Fluid & electrolytes management
 Parenteral antibiotics
 Early laparotomy
 Aim of surgery: reduction & incarcerated
bowel, resection of non viable bowel &
closure of defect

13.  RLQ pain, may mimic acute appendicitis
 Radiology: small bowel loops in Right
paracolic gutter

15.  Small bowel (2/3rd), caecum, ascending
colon, gall bladder, transverse colon &
omentum
 Usually Proximal bowel
obstruction features
 Radiology: circumscribed
loops medial & posterior
to stomach

16.  CT findings: bowel loops between IVC and
liver hilum into the lesser sac

17.  3 types: difficult to differentiate radiologically
 Intersigmoidcongenital
 Transmesosigmoidacquired
 Intramesosigmoidacquired

18.  Children  most common
(35%) type  congenital
defects in mesentery
 Adults  acquired

19.  Herniation through un natural opening
 post surgical:
 RYGB
 Liver transplant
 Trauma
 infections

20.  Gastric pouch
formation
 Proximal end of Roux
limb is attached to
gastric pouch
 Distally jejunao-jejunal
ananstomosis is done

21.  Abdominal pain within 3 months of surgery,
one should always suggest the possibility
of internal hernia
 Incidence is approximately 3%

22.  Mesocolic space: through an
iatrogenic opening in the
mesocolon).
 Peterson hernia: behind
Roux (alimentary) limb
 Distal mesenteric space:
between the 2 leaves of
mesentery at the distal
anastomosis

23.  Transmesenteric
 Retroanastomotic

24.  Early diagnosis & prompt management is
important to prevent strangulation
 Acquired internal hernias can be prevented