Internal hernia. Report of nine cases

Abstract

Internal abdominal hernias are rare and develop when one or more viscera protrude through an intraperitoneal orifice while remaining within the peritoneal cavity. This orifice may be normal (Winslow's foramen) or paranormal (peritoneal fossae) ; these hernias possess a sac and are true hernias. Protrusion may be through a pathologic hole, without a sac, realizing an internal prolapse or procidentia. The clinical diagnosis is always difficult and leads to an urgent operation for intestinal obstruction. The treatment is often simple and the results are generally excellent.Internal herniation is a rare condition. In the literature, some case reports have been described, but rarely series. In that of Gullino (1993), fourteen cases are presented and the incidence of these hernias is estimated at between 0,2 and 2% of abdominal hernias, and o.z to 0.9% of autopsies. Often manifesting by intestinal obstruction, diagnosis is usually made at surgery.The aim of our study is to report 9 cases of internal hernia representing different anatomical types. Material and methodsNine patients of a mean age of 71 (range 51-84) were admitted to our department during a period of eighteen years (from 1979 to 1996). Sex 7M/2F. Eight were symptomatic: six presented a clinical picture of small bowel obstruction, two of peritonitis.Only one patient was asymptomatic, the internal hernia was incidentally discovered during surgical exploration for another pathology (gastric cancer).The two cases of peritonitis were: a 66-year-old man with an ileocecal hernia, which required a 45 cm small bowel resection; a 7o-year-old man with a hernia through the foramen of Winslow; a 1 m small bowel resection was necessary but he died during the urgent operation, complicated by fecal peritonitis.The diagnosis was established preoperatively in two cases out of the eight symptomatic patients (or at least there were strong criteria of such a presumed diagnosis).Eight patients (of the nine) were explored urgently (7 midline incisions, 1 transverse). Reduction of the herniated viscera was never a problem but in one case through the foramen of Winslow. Bowel necrosis was found in two cases, which required resection of 1 m and 45 cm of small bowel with immediate restoration of continuity. The closure of peritoneal fossae or an abnormal orifice was done easily with a resorbable suture, while nothing was attempted on the foramen of Winslow. ResultsThere were two deaths: one intra-operatively due to fecal peritonitis, the other was after an inguinal hernia and three successive operations for intestinal obstruction. Both were elderly (over 70) and presented a Winslow's foramen hernia.

Hernie interne du ligament falciforme: une cause rare d'occlusion intestinale

“…Les hernies internes sont des protrusions des viscères creux abdominaux dans un orifice intrapéritonéal, mais qui restent à l'intérieure de la cavité abdominale [3]. Elles constituent une cause rare d'occlusion intestinale aiguë chez l'adulte [4]. Selon leur siège, on distingue par ordre de fréquence décroissante les hernies para-duodénales, les hernies para-caecales, les hernies trans-mésentériques, les hernies méso-sigmoïdiennes et les hernies para-vésicales [3-6].…”

Answer to Case of the Month #161

“…Internal hernias occur where there is persistent or intermittent displacement of 1 or more viscera through an intraperitoneal orifice [1,2]. They may occur through an orifice that is normal (ie, foramen of Winslow), paranormal (ie, paraduodenal, ileocecal, retrocecal, paracolic, paravascular, etc), or pathologic (ie, transmesenteric, transmesocolic, or transomental) [2]. Internal hernias are relatively infrequent and account for 5% of all abdominal hernias and only 0.2%e 0.9% of all cases of intestinal obstruction [1,3].…”

“…Barium enemas may also demonstrate an unfixed mobile right colon or even complete malrotation of the large bowel [8]. Also, in small intestine involvement, the terminal ileum may be seen ascending alongside the ascending colon in the direction of the epiploic foramen, with compression of the transverse colon by distended intestinal loops [2]. Barium swallows will show the anterior and lateral displacement of the stomach and its distinct relationship to the centrally located gas collection [5,8].…”

“…Barium swallows will show the anterior and lateral displacement of the stomach and its distinct relationship to the centrally located gas collection [5,8]. It may also show obstruction of the body of the stomach from the pressure of the retrogastric mass and the stomach stretched in a crescenteric form [2,8]. The small bowel will be in an abnormal position if involved.…”