INTERNAL HERNIAS

DR.NILESH TULASKAR

INTERNAL HERNIAS
Protrusion of the viscera through the
peritoneum or mesentery and into a
compartment .
The responsible hernial orifices are
usually preexisting anatomic structure
such as foramina, recesses and fossae.
Internal hernia is a rare cause of small
bowel obstruction.(0.6-5.8%)
The incidence is only 0.2-0.9%.

PREDISPOSING FACTORS
Internal hernia may be Congenital and
Acquired.
Congenital anomalies in form of intestinal
rotation and mesenteric attachment.
Acquired- Surgical,Traumatic,Inflammatory
and Circulatory pathology.
Internal hernia may be persistent or
intermittent.

TYPES OF INTERNAL HERNIA

A Paraduodenal:-53%
B Foramen of winslow:8%
C Intersigmoid:-6%
D Pericaecal:-13%
E Transmesenteric:-8%
F Retroanastomotic-5%
G Transomental:-1-4%
H Supravesical & Pelvic:6%

CLINICAL PRESENTATION
Clinical symptoms may range from
intermittent and mild digestive complaints
to acute-onset intestinal obstruction.
Internal hernias are silent if they are easily
reducible, but the majority often cause
epigastric discomfort, periumbilical pain.
Recurrent episodes of intestinal obstruction .
Internal hernias are clinically apparent only
when obstruction and strangulation occurs.

DIAGNOSIS
Clinical diagnosis of internal hernia is
difficult.
The diagnosis should always be
considered when cause of obstruction
remain unknown despite detail
diagnostic workup.

IMAGING STUDIES
Plain X ray abdomen
USG abdomen
Barium enhanced studies/
Enteroclysis.
CT abdomen
But enteroclysis is C/I in Closed loop
obstruction and suspected hernial
strangulation.

PARADUODENAL HERNIA
ANATOMY:
Paraduodenal fossae originate as
congenital peritoneal anomalies
owing to failure of mesenteric fusion
with the parietal peritoneum and an
associated abnormal rotation beneath
the developing colon.

Duodenal fossae
Superior duodenal
Inferior
duodenal(fossa of
Treitz)
Paraduodenal(fossa
of Landzert)
Intermesocolic(fossa
of Broesike)
Mesentericoparietal(f
ossa of Waldayer)

Left Paraduodenal Hernia

Most common 40%
Develops through the fossa of Landzert an
aperture present in approximately 2% of
the population
The fossa of Landzert is located at the
duodenojejunal junction, which is a zone of
confluence of the descending mesocolon,
transverse mesocolon, and small bowel
mesentery

Left Paraduodenal Hernia

Landzert's fossa is formed by
the lifting up of a peritoneal
fold by the inferior
mesenteric vein and
ascending left colic artery as
they run along the lateral
side of the fossa.
Small-bowel loops prolapse
posteroinferiorly through the
fossa to the left of the fourth
part of the duodenum into
the left portion of the
transverse mesocolon and
descending mesocolon.

CT FINDINGS
Abnormal cluster or saclike
mass of dilated small
bowel loops lying between
the pancreas and stomach
to the left of the ligament
of Treitz
Mass effect on the
posterior stomach wall ,
engorgement and
crowding of the mesenteric
vessels with frequent right
displacement of the main
mesenteric trunk, and
depression of the
transverse colon

Right Paraduodenal Hernia

Right PDH involves
the fossa of
Waldeyer which is
located immediately
behind the superior
mesenteric artery
and inferior to the
transverse segment
of the duodenum

Right Paraduodenal Hernia

In these situations, the herniated
contents are located in the right half
of the transverse mesocolon and
behind the ascending mesocolon.
The superior mesenteric artery and
right colic vein are located at the
anterior-medial border of the
encapsulated small bowel loops and
are a landmark for right PDH

Foramen of Winslow Hernia

ANATOMY
The lesser sac and the
greater peritoneal cavity
communicate through the
epiploic foramen of
Winslow.
This foramen is located
anterior to the inferior
vena cava and posterior to
the hepatoduodenal
ligament, including the
portal vein, common bile
duct, and hepatic artery .

PREDISPOSING FACTORS
Enlarged foramen of Winslow.
An abnormally long small-bowel mesentery
Persistence of the ascending mesocolon
allowing marked mobility of bowel
Elongated right hepatic lobe (such as a
Riedel's lobe), which is thought to direct the
mobile intestinal loops toward the foramen of
Winslow .
An ascending colon that is not fused to the
parietal peritoneum.

Features
most commonly involved is the small
intestine (60%70%).
The terminal ileum, cecum, and ascending
colon are involved ( 25%30%)
Hernias involving the transverse colon,
omentum, and gallbladder are rare.
The cecum and ascending colon may be
absent from their usual locations if they are
part of the herniated viscera.

IMAGING STUDIES
Plain Xray Abdomen
s/o gas-containing
intestinal loops high in
the abdomen and
medial and posterior to
the stomach associated
with SBO.
Barium-study of the
small intestine shows
dilatation of bowel loops
and usually reveals the
obstruction at the right
upper abdomen

CT FINDINGS
Presence of mesentery
between the inferior vena
cava and main portal vein.
An air-fluid collection in the
lesser sac with a beak
directed toward the
foramen of Winslow.
Absence of the ascending
colon in the right gutter
Two or more bowel loops in
the high subhepatic spaces

Transmesenteric Hernias
ANATOMY
The small bowel mesentery is a broad, fanshaped fold of peritoneum that suspends the
loops of the small intestine from the posterior
abdominal wall.
In children, transmesenteric hernias are the
most common type of internal hernia, occurring
in 35% of this patient population.
In this age group, they are thought to arise
from a congenital defect in the small-bowel
mesentery, near the ileocecal region or ligament
of Treitz

Etiologic hypotheses for

Congenital defects
Partial regression of the dorsal mesentery.
Fenestration during the developmental
enlargement of an inadequately
vascularized area,
An ileocecal mesentery with considerable
and rapid lengthening in fetal life.
.

Transmesenteric Hernias
In adults,most
mesenteric defects are
probably the result of
surgery, trauma, or
inflammation.
Retrocolic type of Rouxen-Y anastomosis is
more associated with
the potential
complication of
transmesenteric
internal hernia.

FEATURES
Transmesenteric hernias are more likely than
other subtypes to develop volvulus and
strangulation or ischemia because of the
absence of a limiting hernial sac allowing a
large length of small bowel to herniate
through the mesenteric defect.
Patients present with signs and symptoms of
small-bowel obstruction.
Observation of the clustering of small bowel
loops and abnormalities of the mesenteric
vessels plays an important role in diagnosis
of transmesenteric hernia.

CT FINDINGS
Mesenteric vascular
pedicle is engorged,
stretched, and
crowded
Converging mesenteric
vessels are located at
the entrance of the
hernial sac.
There is displacement
of the main
mesenteric trunk .

Transomental Hernia
Mostly occur in right side of Greater omentum.
Small bowel loops, the cecum and the sigmoid
colon are involved in this defect.
The clinical and radiologic findings are almost
identical to those of transmesenteric hernias

Transomental Hernia
Two types:
1) Herniation occurs
through a free greater
omentum; this type is
more common. No sac is
present
The hernial orifice on the
greater omentum is
located in the periphery
near the free edge.
2) Herniation into the
lesser sac occurs through
the gastrocolic ligament
.Rare

Pericecal Hernia
ANATOMY
The pericecal fossa
is located behind
the cecum and
ascending colon and
is limited by the
parietocecal fold
outward and the
mesentericocecal
fold inward.

PERICECAL RECESSES
Superior ileocecal
recess
Inferior ileocecal
recess
Retrocecal recess
Paracolic sulci

FEATURES
most commonly the
herniated loop consists
of an ileal segment
protruding through a
defect in the cecal
mesentery and
extending into the right
paracolic gutter.
Clinical diagnosis is
difficult
Diagnoses are confused
with inflammatory bowel
disease, appendiceal
disorders.

IMAGING STUDIES
Barium enema
shows retrograde
filling of herniated
distal ileum as
loops of ileum pass
posterior to cecum
through defect of
ileocecal mesentery
to reach right
paracolic fossa.

CT FINDINGS
A cluster of fluid-filled
small bowel loops located
lateral to the cecum and
posterior to the ascending
colon.
Beaking appearance
indicative of tethering at
the aperture of the
peritoneal recess.
Dilatation of small bowel
loops with a transition
zone were revealed

Sigmoid Mesocolon Hernia

ANATOMY
The sigmoid mesocolon is a peritoneal fold attaching the
sigmoid colon to the pelvic wall.

The apex is divided near the left common iliac artery

and serves as a potential site for an internal hernia.

The intersigmoid fossa lies behind this apex of the Vshaped parietal attachment of the sigmoid mesocolon.

FEATURES
Intersigmoid hernia
-Herniation into a congenital fossa,
the intersigmoid fossa, a peritoneal
pouch located between the two loops
of the sigmoid colon and its
mesentery.
-Are usually reducible and are an
incidental finding during laparotomy.

Sigmoid Mesocolon Hernia

Transmesosigmoid hernia
Incarceration of small
bowel loops through a
defect in the sigmoid
mesocolon.

Transmesosigmoid
hernia involves both
layers of the sigmoid
mesentery and allows
herniation of the small
bowel loops toward the
left lower abdomen,
posterior-lateral to the
sigmoid colon.
-

Sigmoid Mesocolon Hernia

Intermesosigmoid
hernia
Incarceration
with a hernial sac
through a
congenital defect,
present in only one
of the constituent
leaves of the
sigmoid mesentery.

CT FINDINGS
Dilated small-bowel
loops entrapped
behind the left
posterior and lateral
aspect of the sigmoid
colon, with the defect
most commonly
located between the
sigmoid colon and the
left psoas muscle, or
between sigmoid loops
if it is an intersigmoid
type

Supravesical Hernia
The supravesical fossa is the area of
the abdominal wall between the
remnants of the median and the left
or right umbilical ligaments.
Two types
External supravesical hernia
Internal supravesical hernia

Supravesical Hernia
The sac may remain above the pelvis and
form an external supravesical hernia.
External supravesical hernia is more
common than internal supravesical hernia,
and it is difficult to make differential
diagnosis from inguinal hernia.
External supravesical hernia presented with
inguinal swelling and were diagnosed as
having direct inguinal hernia

Supravesical Hernia
The sac may pass downward into the
pelvis and form an internal supravesical
hernia.
Internal supravesical hernia presented
with intestinal obstruction and
strangulation.
The characteristic CT finding of the
supravesical hernia is the incarcerated
small bowel loops in front of the
bladder.

Hernia through the Broad

Ligament
The broad ligaments
extend from the sides
of the uterus to the
lateral pelvic walls.
The herniated viscus is
the small intestine in
more than 90% of
cases.
More than 85% of
these hernias have
occurred in parous
women.

 Broad ligament defects are classified as

congenital or acquired.
Congenital due to a developmental
peritoneal defect around the uterus.
Acquired defects are due to surgical
trauma, pregnancy and birth trauma,
perforations following vaginal
manipulation and prior pelvic
inflammatory disease .

Classification
On the basis of the anatomic position of
the defect:
Type 1 : defect caudal to the round
ligament.
Type 2 : defect above the round
ligament.
Type 3 : defect between the round
ligament and the remainder of the broad
ligament through the mesoligamentum
teres.

CT FEATURES
Cluster of dilated
small bowel loops
with air-fluid levels
in the pelvic cavity.
Bowel loops
compressing the
rectosigmoid
dorsolaterally and
the uterus ventrally
.

TREATMENT
Partial obstruction can initially be managed
with conservative treatment
In acute-onset and high-grade SBO, have
recommended direct surgical exploration.
When clinical diagnosis of intestinal
obstruction has been established, abdominal
wall hernias excluded and no previous
history of surgery, a diagnostic laparoscopy
should be performed.
Timing of laparoscopy also very crucial.

Definative Treatment
Reducing the hernia.
Resection and Primary anstomosis of
bowel if not viable.
Repairing the defect.

Diaphragmatic Hernias
A rent in the
diaphragm that
allows herniation
of abdominal
viscera into the
thoracic cavity.
Types:
Congenital
Acquired
Hiatal hernia
Traumatic

Congenital Diaphragmatic
Hernias (CDH)
One of the most common congenital abnormalities
Incidence 1 in 2000 to 5000 births
One third of infants with CDH are stillborn, usually
due to associated fatal anomalies like neural tube
defects and cardiac defects
Defects are common on left side (80%) compared to
right (20%)
CDH is usually a disorder of the newborn period, as
many as 10% of patients may present after the
newborn period and even during adulthood. Outcome
in patients with late presentation of CDH is extremely
good, with low or no mortality

Congenital Diaphragmatic
Hernias (CDH)
Bilateral CDH defects are rare
Sporadic developmental anomaly,
although familial cases have been
reported
Expected risk in a 1st degree relative is 1
in 45
One third have associated major defects
Combination of CDH and abnormal
karyotype is associated with poor
outcome

Congenital Diaphragmatic
Hernias (CDH)
Cause is unknown. Failure of normal closure
of the pleuroperitoneal canal in the
developing embryo.
Abdominal contents herniate and compress
the ipsilateral developing lung, causing
pulmonary hypoplasia and hypertension
Presumed combination of intrinsic
predisposition (genetic) and environmental
insult (teratogen or deficiency)
Pharmacological agents like quinine,
thalidomide, nitrofen, phenmetrazine

Congenital Diaphragmatic
Hernia
Associated with genetic anomalies:
Cornelia de Lange syndrome
DiGeorge syndrome
Chromosome 15,18,13 and 21
anomalies
Fryns syndrome
Pallister-Killian syndrome

Congenital Diaphragmatic
Hernias (CDH
Types of
Congenital
Diaphragmatic
Hernias (CDH)

Bochdalek
Morgagni
Diaphragmatic
eventration
Central tendon
defects

Bochdalek Hernia
Postero-lateral diaphragmatic hernia
Most common manifestation of CDH,
accounting for more than 95% of cases
Majority of Bochdalek hernias (80-85%) occur
on the left side of the diaphragm
A failure of the diaphragm to completely close
during development.
Defect in development of pleuroperitoneal
membrane.
Herniation of the abdominal contents into the chest
leads to Pulmonary hypoplasia.

Morgagni Hernia
anterior medial defect of the diaphragm
referred to as Morgagnis, retrosternal, or
parasternal hernia
accounts for approximately 2% of all CDH cases
characterized by herniation through the
foramina of Morgagni which are located
immediately adjacent to the xyphoid process of
the sternum
majority occur on the right side of the body and
are generally asymptomatic.

Diaphragmatic eventration
abnormal displacement ( elevation) of part
or all of an otherwise intact diaphragm into
the chest cavity
diaphragm is thinner in the region of
eventration, allowing the abdominal viscera
to protrude upwards
thinning is thought to occur because of
incomplete muscularisation of the
diaphragm
Minor forms of diaphragm eventration are
asymptomatic

Clinical presentation:
- Dyspnea
- Tachypnea
-Cyanosis
-Severe retractions of respiratory
muscles
-Scaphoid abdomen
-Large antero-posterior diameter of
chest

Diagnosis
Often made on prenatal ultrasound
exam.
Prenatal MRI when obstetric US has
detected a complex fetal anomaly.
After birth, spectrum of respiratory
symptoms depend on degree of
pulmonary hypoplasia and pulm HTN.
Respiratory distress at birth within first
24 hours of life.

Diagnosis
Affected infants have a scaphoid
abdomen
Location of stomach is confirmed by
placement of a NGT.
Chest x-ray demonstrates loops of
intestines in the chest.
CXR shows shifting of cardiac silhouette
into contralateral thorax.
CXR is unreliable for estimating degree of
pulmonary hypoplasia.

Chest Xray

Treatment
CDH is a physiologic emergency and
not a surgical emergency
Pregnant mother should be referred
to appropriate tertiary perinatal
center where full array of respiratory
care strategies ( ventilators, ECMO)
are available
Endotracheal intubation and NGT
insertion should done.

Treatment
Bag-mask ventilation is contraindicated
to avoid distension of stomach and
intestines in thoracic cavity
Most infants can be successfully
managed with pressure-cycled
ventilator
Goals of respiratory support are PaO2
> 60 and PaCO2 < 60

Treatment
Extremes of hyperventilation (high rates
and high pressures) should be avoided
High frequency technologies like jet
ventilator or oscillating ventilator may
be required
Antihypertensives to decrease
pulmonary HTN .
ECMO if everything fails

Treatment
The definitive treatment for any of the
hernias described is surgical repair of the
defect in the diaphragm and replacement of
any abdominal viscera that was herniated
back into the thoracic cavity
Patients with traumatic hernias are first
stabilized and rested before proceeding
with surgery unless life-threatening
hypoventilation, caused by abdominal
viscera compressing the lungs, occurs

Surgery
Delayed surgical repair is now widely
placed
Most institutions perform surgery in
NICU
When diaphragmatic tissue is adequate,
primary repair with nonabsorbable
suture can be done
If the defect is too large, prosthetic
material can be used for a tension-free
repair

Congenital Diaphragmatic
Hernia
Approaches for surgical repair:
Abdominal subcostal
Thoracotomy
Laparoscopic vs Thoracoscopic
Laparoscopy for Bochdaleks hernia has a high
failure rate and is associated with pCO2 and
acidemia
Contraindicated if very high pCO2.
Thoracoscopy is better approach for Bochdalek
hernias with recurrence of 14%. .(Marjorie et
al, J Ped Surg, Nov 2003.)

Congenital Diaphragmatic
Hernia

Outcome
Survival rates for isolated CDH have
improved dramatically (>90%)
Major predictor of survival is
resolution of pulmonary HTN
In the survivors, long term problems
include chronic lung disease,
developmental delay, nutritional and
growth related problems

Hiatal Hernia
Protrusion of the
stomach upward
into the mediastinal
cavity through the
esophageal hiatus
of the diaphragm
Sliding
90% of cases
Rolling
(paraesophageal)

-Mixed

Sliding Hiatal Hernia

Characterized by an
upward dislocation
of the cardia in the
posterior
mediastinum
Increased
abdominal pressure
and vigorous
esophageal
contraction result
hernia

Paraesophageal Hiatal Hernia

Characterized by an
upward dislocation
of gastric fundus
alongside a normally
positioned cardia.
It is uncommon.
Weakening of
phrenoesophageal
membrane.

Type III Hiatal Hernia

It is combined with type I and type II.
It is frequently present when a type II
hiatal hernia have been present for
many years

A Comparison of the normal stomach,

sliding hiatal hernia and rolling hiatal
hernia

Clinical Features of Hernias

Sliding hiatal
hernia

Heartburn
Regurgitation
Chest pain
Dysphagia
Belching

Paraesophageal
hernia
Feeling of fullness
and breathlessness
after eating
Feeling of
suffocation
Cheat pain that
mimics angina
Symptoms worse in
recumbent position

Complications

Bleeding
Anemia
Pulmonary Aspiration
Volvulus
Obstruction
Strangulation
Perforation
Acute dilatation of intrathoracic stomach

DIAGNOSIS
The diagnosis is suspected first on the CXR.
The most common finding is retrocardiac
bubble with or without air-fluid level.
In a giant hiatal hernia, the herniated organ
may be found in the right thoracic cavity .
The barium study of the UGI confirms the
diagnosis.
Endoscopy and esophageal function test can
detect the function of LES.
Fibreoptic oesophagoscopy is useful in
diagnosis and classification of hiatal hernia.

THERAPY
There is no accepted medical
treatment for hiatal hernia.
Surgery is indicated to prevent
complications.
In type II hernia, if gastric volvulus or
obstruction is present without toxic
signs, NG decompression must be
performed. The surgery is scheduled.

Operative Approaches
The principles of operation is reduction of
the hernia, resection of the hernia sac and
closure of the defect.
Transabdominal (open & Laparoscopic)
Reduction of volvulus associated with
Paraoesophageal hernias.
Transthoracic approach
complete oesophageal mobilization and
removal of hernial sac.

Operative Technique:
Conventional Abdominal Approach
In type II hernia, the E-C junction is still
in the abdomen, bounded posteriorly
with a fibrous band. It is careful not to
take down the attachment.
Dissection is done on the lower 4 to 8
cm of the esophagus.
The repair is done with nonabsorbable
sutures.

 Antireflux procedure is done when

significant reflux esophagitis is
present.
A loose Nissen fundoplication is
suggested by authors.
Others like Belsey mark IV procedure.
Hill procedure

Laparoscopic Approach
Principles
Reduction of hernia.
Excision of peritoneal sac.
Crural repair.
Fundoplication

Complications
Temporary dysphagia
Gas bloat syndrome (avoid carbonated
beverages)
Atelectasis, pneumonia
Obstructed NG tube

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