Internal Hernia

Ajit Nihal Ahmad, MD
The Operative Review of Surgery. 2023; 1:296-301.

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Table of Contents

Definitions and Classification
Congenital Anatomic Defects
Management

References

Definitions and Classification

Definition

  • Herniation Through an Opening in the Peritoneum or Mesentery
  • Opening Can Be Congenital or Acquired

Types 1

  • Paraduodenal 2,3
    • Historically the Most Common (53%) – Not Anymore Given Frequency of Newer Laparoscopic Procedures
  • Foramen of Winslow 4
    • Herniation Through the Foramen of Winslow into the Lesser Sac
  • Peri-Cecal 5
    • Herniation in the Pericecal Fossa
  • Inter-Sigmoid 6
    • Herniation Through the Intersigmoid Fossa
    • Most Often Easily Reducible
    • Debated if it is a True Aperture/Hernia
  • Supravesical 7
    • Herniation into the Space of Retzius
    • Can Be Anterior, Lateral, or Posterior to the Bladder
  • Trans-Omental 8
    • Herniation Through the Greater or Lesser Omentum
  • Trans-Mesenteric 9
    • Herniation Through a Complete Defect in the Mesentery
    • Either from a Congenital Defect or from a Surgical Defect (Retrocolic Roux-en-Y)
  • Retro-Anastomotic
    • Related to a Surgical Anastomosis – Reduce Risk by Closing All Mesenteric Defects 10
    • Risk After Roux-en-Y Gastric Bypass: 2-5% 11,12
    • Risk After Laparoscopic Colorectal Surgery: 0.65% 13

Paraduodenal Hernias

  • Left Paraduodenal Hernia: Herniation Through Landzert’s Fossa 2
    • More Common Than on the Right (75%)
  • Right Paraduodenal Hernia: Herniation Through Waldeyer’s Fossa 3

Sigmoid-Related Hernias

  • Inter-Sigmoid: Herniation Through the Inter-Sigmoid Fossa 6
    • Most Often Easily Reducible
    • Debated if it is a True Aperture/Hernia
  • Trans-Mesosigmoid: Herniation Through a Complete Defect in the Sigmoid Mesocolon 14
  • Intra-Mesosigmoid: Herniation into an Incomplete Defect in the Sigmoid Mesocolon Through Only a Single Layer with the Sac Inside the Sigmoid Mesocolon 15
    • Most Commonly the Left

Mesenteric Defects After a Roux-en-Y Gastric Bypass

  • Petersen’s Space: Mesenteric Defect Between the Roux Limb Mesentery and Transverse Mesocolon
  • Brolin’s Space (Mesojejunal Window): Mesenteric Defect at the Jejunojejunostomy
  • Transverse Mesocolon Defect: Mesenteric Defect Under the Transverse Colon
    • The Most Common Site 16
    • Only Present After Retrocolic Procedures, Not in Antecolic Procedures
  • *See Roux-en-Y Gastric Bypass

Sites of Internal Hernia: (1a) Left Paraduodenal Hernia; (1b) Right Paraduodenal Hernia; (2) Foramen of Winslow Hernia; (3) Pericecal Hernia; (4) Sigmoid-Related Hernia; (5) Transmesenteric Hernia; (6) Transomental Hernia; (7) Supravesical Hernia 17

Left Paraduodenal Hernia 18

Right Paraduodenal Hernia; (A) Normal Anatomy, (B) Right Paraduodenal Hernia 19

Sigmoid-Related Hernias; (a) Intersigmoid, (b) Trans-Mesosigmoid, (c) Intra-Mesosigmoid 20

Mesenteric Defects After Roux-en-Y Gastric Bypass; (1) Petersen’s Space, (2) Brolin’s Space, (3) Transverse Mesocolic Window (Only in Retrocolic Bypass) 21

Congenital Anatomic Defects

Landzert’s Fossa

  • Present in 2% of the Population
  • Located Behind the Fourth Portion of the Duodenum
  • Formed by the Mesenteric Fold from the IMV and Left Colic Artery
  • Site of a Left Paraduodenal Hernia

Waldeyer’s Fossa

  • Present in < 1% of the Population
  • Located Under the Third Portion of the Duodenum
  • Formed by the Mesenteric Fold from the SMA
  • Site of a Right Paraduodenal Hernia

Foramen of Winslow

  • Also Known as the Epiploic or Omental Foramen
  • Communication Between the Greater Sac and Lesser Sac
  • Anteriorly Bordered by the Hepatoduodenal Ligament

Pericecal Fossa

  • Located Behind the Cecum/Ascending Colon
  • Subtypes:
    • Ileocolic Fossa
    • Ileocecal Fossa
    • Retrocecal Fossa
    • Paracecal Fossa

Intersigmoid Fossa

  • Present in 65% of the Population
  • Formed Between 2 Adjacent Sigmoid Segments and Their Mesentery
  • Debated if it is a True Aperture

Supravesical Fossa

  • Triangular Area Bounded by the Peritoneal Reflection Over the Dome of the Bladder and the Lateral Umbilical Folds
  • Space of Retzius: Potential Space Below the Supravesical Fossa, Between the Pubic Symphysis and Bladder

Paraduodenal Hernia Fossae; (a) Waldeyer’s Fossa, (b) Landzert’s Fossa, (c) Retroperitoneum, (d) Hernial Orifice 22

Foramen of Winslow 23

Pericecal Fossa 24

Incision into the Space of Retzius 25

Management

Presentation

  • Presentation is Mostly Nonspecific
  • Can Be Asymptomatic
  • Small Bowel Obstruction (SBO)
  • Chronic Postprandial Pain
  • Closed-Loop Obstruction Creates a High Risk for Bowel Ischemia, Strangulation, and Perforation

Diagnosis

  • Primarily Made by CT
  • CT Findings: 26,27
    • Small Bowel Obstruction
    • Closed-Loop Obstruction
    • Mesenteric “Swirling”
    • Small Bowel Herniation into an Abnormal Location – Requires Sufficient Knowledge of Anatomic Spaces
    • “Mushroom Sign” – Herniated Bowel Resembling a Mushroom with the Constricted Mesenteric Pedicle Resembling a Mushroom Stalk
  • May Be Found Intraoperatively if Not Diagnosed Preoperatively

Treatment 28-31

  • Diagnosis Mandates Urgent Surgical Exploration
  • Potential Interventions:
    • Hernia Reduction
    • Bowel Resection
    • Defect Closure
  • Exploration Cen Be Done Open or Minimally Invasive

Peterson’s Hernia; (A) AXR Showing SBO, (B) CT Showing Mesenteric Swirl Sign 32

References

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  5. CUTHBERT FP, SMITH PE. Pericecal hernia; case report. Ohio State Med J. 1961 Jan;57:48-50.
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