What Is The Procedure To Repair An Inferior Periumbilical Hernia Containing Mesenteric Fat
Earth J Gastrointest Endosc. 2022 Jun sixteen; iii(6): 110–117.
Abdominal hernias: Radiological features
Received 2022 Jan 15; Revised 2022 May two; Accustomed 2022 May 16.
Abstract
Abdominal wall hernias are common diseases of the abdomen with a global incidence approximately 4%-five%. They are distinguished in external, diaphragmatic and internal hernias on the footing of their localisation. Groin hernias are the most common with a prevalence of 75%, followed by femoral (fifteen%) and umbilical (8%). There is a college prevalence in males (M:F, 8:1). Diagnosis is usually fabricated on physical examination. However, clinical diagnosis may be difficult, especially in patients with obesity, pain or abdominal wall scarring. In these cases, abdominal imaging may be the first inkling to the right diagnosis and to confirm suspected complications. Different imaging modalities are used: conventional radiographs or barium studies, ultrasonography and Computed Tomography. Imaging modalities can aid in the differential diagnosis of palpable intestinal wall masses and can assistance to define hernial contents such as fatty tissue, bowel, other organs or fluid. This work focuses on the main radiological findings of intestinal herniations.
Keywords: Intestinal Radiology, Hernia, Abdominal Obstruction, Abdominal Wall, Hiatal Hernia, Internal Hernia, External Hernia, Diagnostic Radiology, Computed tomography, Ultrasonography
INTRODUCTION
Abdominal herniation is a protrusion of part of its content from the abdominal crenel through a normal or abnormal aperture or from wall weakness[1]. Hernias may be built or acquired. The first announced prenatally or in infants and are acquired by a congenital defect provoking an opening in the abdominal cavity. The second may be caused by atmospheric condition that increase the pressure in the abdominal cavity (obesity, cough, straining), from previous surgical procedure (incisional hernia) or from trauma.
Nosotros tin can distinguish three main types of hernias: external, diaphragmatic and internal. The protrusion in external abdominal herniation occurs through an opening of the abdominal wall[1], while internal herniations happen across mesenteric or peritoneal apertures. Finally, diaphragmatic herniation involves a weakness of the diaphragm.
Abdominal wall hernias are common diseases of the abdomen with a global incidence approximately four%-v%[2]. They correspond 1 of the most common reasons for emergent surgery performed in patients over l years sometime[iii,four]. In fact, they are the second most common indication for surgery after acute appendicitis in Europe and the Usa[5].
Groin hernias are the about common with a prevalence of 75% followed by femoral (15%) and umbilical (viii%)[ii]. Mostly at that place is a higher prevalence in males (G:F, 8:1). However for anatomical reasons, women are more than afflicted by femoral hernias[3]. The most mutual cause of hernia in the newborn is congenital malformation, in adults, wall stress and in the elderly, weakness of the intestinal wall.
In that location are many different types of hernias with a wide range of dissimilar clinical conditions. Symptoms of abdominal herniations may exist absent or non-specific, consisting of balmy abdominal discomfort alternating with episodes of intense periumbilical pain and nausea[1]. In some cases, withal, they may develop acute complications (incarceration, bowel obstruction, volvulus and strangulation) that necessitate prompt diagnosis and therapy[3].
Diagnosis is usually fabricated at physical examination; still, clinical diagnosis tin can exist difficult, especially in patients with obesity, pain or abdominal wall scarring. In these cases, abdominal imaging may be the first clue to the correct diagnosis[3] and to confirm suspected complications of hernias. Different modalities imaging are used: conventional radiographs or barium studies, ultrasonography (US) and computed tomography (CT). In add-on, the cross-exclusive imaging modalities, sonography and CT, can aid in the differential diagnosis of palpable abdominal wall masses and help to define hernial contents such equally fatty tissue, bowel, other organs or fluid[half-dozen].
Conventional radiological techniques provide a useful diagnostic tool to allow detection of the presence and type of hernia and organ involvement. In particular, radiology permits detection of signs of mechanical ileus with bowel loops enlargement, thickening of intestinal folds and air-fluid levels [half-dozen]. In emergency cases, a directly exam is commonly performed and in non emergencies, a contrast enhancement may be washed using a radio opaque contrast agent (barium or water-soluble iodinated in case of obstruction or perforation) that allows gastrointestinal opacification and delineation later on oral or rectal administration. These methods are valuable, allowing skilful diagnostic accuracy, showing any structural aberration, filling defects and the position and rapports of an opacified organ, recognizing eventual dislocation.
US imaging, like CT, largely finds a mass in the abdominal wall corresponding to the contents of the hernia sac and distinguishes it from other masses such as cysts, hematomas, neoplasms or varicoceles[seven]. The states may disembalm the presence of the hernia signs (Effigy 1) and is particularly useful in pocket-size midline hernias containing mesenteric fat or to study the pediatric population. The states may detect the presence of hernias in the groin with a complete regional evaluation and hiatal hernias. A dynamic written report of the gastro-esophageal junction is also possible. In a example of complications, U.s. may provide data on the herniated organs and repercussions in the peritoneal crenel. Signs of mechanical ileus and of decompensation with the presence of peritoneal fluid, the presence or absence of color Doppler signals in the hernial contents and the presence or absence of peristalsis in the herniated bowel loop may be detected[6]. An important sign, with high specificity just limited sensitivity, of incarceration is fluid in the herniated bowel loop with bowel wall thickening and complimentary fluid in the hernial sac. In the evaluation of the groin area, Usa imaging has an advantage over CT in the power to evaluate the standing patient, with alternate straining and relaxation[7].
Ultrasonography of Strangulated midline hernia. Hyperechoic haemorrhagic loops surrounded by a transonic (black) thin film of fluid.
For these reasons, U.s.a. is really helpful in patients with inconclusive or misleading clinical presentations[vi]. US is not-invasive, allows for comparing with the asymptomatic side and can be performed in physiological positions with dynamic scanning; for these reasons it plays a primal role in evaluating the presence of complications such equally strangulation or incarceration and, in some cases, The states may detect further pathology in the hernial sac. Operator dependency and the relatively long learning curve are limiting factors. Furthermore, the presence of intestinal gas, often prominent in acute patients, limits the performance of U.s.a. in emergency conditions.
Among radiological techniques, CT performs better than others, providing an accurate and panoramic view of the abdomen. Advantages of CT include more accurate identification of hernias and their contents and differentiation of hernias from other abdominal masses (tumors, hematomas, abscesses, undescended testes and aneurysms)[8]. Furthermore, because of its superior anatomic detail, multi - detector row CT may help detect subtle signs of complication within the hernia sac, including bowel obstruction, incarceration, strangulation and traumatic wall hernia[8].
CT is also useful in evaluating mail service-surgical patients, especially those with enlarged masses or exuberant scars. In obese patients, CT helps determine the shape, location and content of abdominal wall hernias[3]. This work focuses on the main radiological findings of abdominal herniations in conventional radiography, U.s. and CT studies.
TECHNIQUE
Conventional radiological techniques provide a useful diagnostic tool, assuasive us to observe the presence and type of hernia and organ involvement. In particular, radiology permits detection of signs of mechanical ileus with bowel loops enlargement, thickening of intestinal folds and air-fluid levels[half-dozen].
Contrast enhanced radiology allows a meliorate evaluation of the digestive tract and its relationship with surrounding anatomical structures.
According to some authors, fluoroscopy should exist performed with the patient in the lateral position because about hernias are not clearly visible in frontal or frontal oblique views, although the presence of an anterior abdominal wall hernia is sometimes indirectly indicated on frontal images by displacement and narrowing or deformity of the herniated bowel loops[8]. The reducibility of bowel-containing hernias as well can be assessed during fluoroscopic test. Therefore, fluoroscopy is useful in barium studies for the detection and characterization of intestinal hernias[9].
US is performed with the 3.5 MHz convex probes usually adopted for abdominal examination and with high frequency seven.5 MHz probes to obtain meliorate resolution of the nearest bowel loops. Color-Doppler analysis increases diagnostic ability of the method detecting circulatory alterations. Dynamic report permits checking patency and reducibility of the involved organs[six]. In CT scanning, images are acquired supine, during a single breath-hold, from the diaphragm to the pubic symphysis and somewhen before and later on bolus injection of intravenous iodinated contrast. Technical parameters are called according to the scanner (typically with a 16 piece scanner collimation 1.5 mm, reconstruction slice thickness 2 mm). Multiplanar reformatted (MPR) images, obtained on a workstation, requite important data in improver to that provided by axial images as they may better delineate the size and shape of the hernia sac and associated complications[8] (Figure 2A). MDCT can accurately delineate the blazon of hernia, the location and can place signs of strangulation, such every bit mesenteric stranding, poor bowel wall enhancement, wall thickening, gratis air or fluid in the hernial sac[10].
Computed tomography. A: Coronal reconstruction of a right indirect inguinal hernia. Bowel loops are visible in the hernial sac and the vascular axis passing trough the inguinal culvert; B: Pilot browse. Bladder underlined by the contrast media in a right direct inguinal hernia; C: Axial scan. Bilateral direct inguinal hernia. On the right contains the bladder, on the left intestinal loops. Note the epigastric vessels lateral to the hernia (arrow); D: Obturator hernias. A thickened bowel loop is located between the external obturator and pectineal muscles (pointer); E: Very big hiatal hernia containing also mesenteric fatty and bowel loops; F: Sagittal reconstruction of bockdaleck hernia. The spleen, part of the left kidney and small bowel pass in the thorax through a posterior diaphragmatic defect; G: Thick slab MIP coronal reconstruction of left paraduodenal hernia. Both, the inferior mesenteric vein (white arrow) and the ascending left colic avenue (black arrow) can be seen above the herniated loop along the anterior aspect.
To promote the protrusion of the hernia, some authors perform Valsalva and postural maneuvers (prone or lateral decubitus positioning)[three].
Among radiological techniques, CT performs better than others, providing an accurate and panoramic view of the belly. Advantages of CT include more authentic identification of hernias and their contents and differentiation of hernias from other abdominal masses (tumors, hematomas, abscesses, undescended testes and aneurysms)[viii]. When muscular layers are intact, CT is very useful for diagnosis. When hernias do exist, CT can bear witness which fascial or muscular layers are involved and the content of the hernial sac[11]. Considering of its superior anatomical detail, multi - detector row CT may help detect subtle signs of complication within the hernia sac, including bowel obstacle, incarceration, strangulation and traumatic wall hernia[8]. This exam is mandatory in the study of the astute belly and is primal in deciding what type of treatment is all-time, surgical or conservative, and is as well useful in evaluating post surgical patients, especially those with enlarged masses or exuberant scars.
EXTERNAL HERNIAS
We tin can split external hernias in 3 types: groin, ventral and posterior.
Groin
Groin hernias are divided into inguinal (direct and indirect) and femoral[3]. Indirect inguinal hernias are the well-nigh common and are caused by the protrusion of peritoneal content through a patent internal inguinal ring, lateral to the junior epigastric vessels. In men, the hernia tin can extend forth the spermatic cord into the scrotum while in women, the hernia may follow the form of the round ligament into the labia majora[12]. The peritoneal sac containing bowel loops protrudes through the inguinal canal and emerges at the external inguinal ring. Retroperitoneal organs such equally the urinary float (Effigy 2B and C), distal ureters or ascending or descending colon may be incorporated into the hernia[12].
Straight hernias extend through an acquired weakness area in the posterior wall of inguinal culvert (the Hesselbach triangle) and laissez passer medially to the inferior epigastric vessels.
Less mutual than inguinal hernias, femoral hernias occur through a congenital defect in attachment of the transverse fascia to the pubis below the inguinal ligament; the hernia passes through the femoral culvert medial to the femoral vein[xiii], beneath the inguinal ligament and lateral to the pelvic tubercle and there is a trend to be right-sided[14]. This type of hernia is more mutual in women considering they accept a wider pelvis that enlarges the egress of the femoral canal. They are more likely to incarcerate and strangulate than inguinal hernias.
Ventral hernias
The ventral grouping includes anterior and lateral abdominal hernias[3]. Anterior defects consist of umbilical, paraumbilical, epigastric and hypogastric hernias[viii].
The umbilicus is a scar at the site of attachment of the umbilical cord in the fetus. During the sixth week of evolution, the intestinal cavity becomes too modest to incorporate the primary intestinal loops and then a physiological hernia occurs. In normal atmospheric condition, at 12 wk, bowel loops are entirely located in peritoneal cavity. In the fetus, the most common congenital anomaly resulting from failed closure of the umbilical ring is omphalocele. The umbilical cord arises from the hernial sac; intra-abdominal structures herniate into the base of the umbilical cord and the hernia is covered by peritoneum, amnion and Wharton's jelly.
Umbilical hernias in adults are usually congenital and result from incomplete closure of the abdominal wall after ligation of the umbilical cord. This kind of hernia often remains asymptomatic. Incomplete herniation of the loop may occur and these are called Richter's hernias.
Caused umbilical hernias develop more than often in obese and multiparous women and strangulation is common.
Epigastric hernias occur on the linea alba betwixt the xiphoid process and bellybutton while hypogastric hernias take place on the midline beneath the umbilicus. By and large, properitoneal fat, vessels and sometimes solid viscera protrude through the hernial defect[12]. Strangulation (ischemia caused by a compromised claret supply) and incarceration (irreducible sac) are mutual in all midline hernias[x].
Amid lateral hernias, the Spigelian (1.v% of the abdominal hernias) is due to built or acquired weakness in the posterior layer of the transverse fascia[12] forth the semilunar line in an surface area located betwixt the rectum sheath and oblique muscles. This defect allows viscera to prolapse between the lateral intestinal wall muscles and course an interstitial hernia. Typically, the omentum or short segmen-
ts of the large or pocket-sized bowel beetle through the hernial defect[12]. This is uncommon simply frequently a crusade of incarceration.
Posterior hernias
Posterior hernias include the lumbar hernias that occur spontaneously, postsurgically or secondary to trauma, especially after pelvic fracture[3]. Herniation tin occur either through defects in the lumbar muscles or the posterior fascia (transversalis or lumbodorsal) in the superior (Grynfeltt-Lesshaft) or inferior (Petit's) lumbar triangles[3]. Those may be built due to defects in the musculoskeletal system (20% of total) or caused (80%). The Grynfeltt-Lesshaft triangle is defined by the quadratus lumborum muscle medially, twelfth rib superiorly, internal oblique muscle laterally and the erector spinal muscle posteriorly[three]. The floor of the triangle is the transversalis fascia and the aponeurosis of the transversalis muscle of the abdomen. The roof of the triangle is the external oblique and latissimus dorsi muscles. The Petit triangle is bordered by the external oblique muscle anteriorly, the latissimus dorsi muscle posteriorly and the iliac crest inferiorly[3]. Bowel loops, retroperitoneal fat or the kidney or other viscera protrude through the hernial defect. Incarceration or strangulation can occur[12].
Less mutual hernias
At that place is another group of less common hernias: sciatic, obturator and perineal hernias.
The obturator hernias, more frequent in elderly women, appear betwixt the external obturator and pectineal muscles[iii]. The peritoneal sac and its contents herniate through the obturator canal in the superolateral aspect of the obturator foramen alongside the obturator vessels and fretfulness and beetle between the external obturator and pectinal muscles or between the layers of the obturator membrane. Occasionally the hernia compresses the obturator nerve, causing pain radiating to the knee. Obturator hernias occur commonly in elderly women. They oft incorporate bowel loops; the appendix, omentum, bladder, uterus or adnexal tissue may also protrude through the hernial defect. Incarceration is frequent (Effigy 2D). In our experience, this kind of hernia is more than oft observed in association with hip prosthesis or severe coxarthrosis, probably due to the induced atrophy in pectineus and external obturators muscles.
The sciatic hernia takes place through the sciatic foramen, in a higher place or below the piriform muscle and under the junior border of the gluteus maximus muscle, frequently involving the small bowel or the distal ureter[3].
Perineal hernias are uncommon, more frequent in older women through the pelvic floor due to acquired weakness of the pelvic floor and are generally adjacent to the anus, the labia majora or gluteral region[3]. They typically occur at areas of weakness in the urogenital diaphragm, elevator ani musculus or coccygeal musculus.
INCISIONAL HERNIAS
Incisional hernia is one of the most common complications of abdominal surgery at sites of a previous laparotomy, with a reported occurrence rate of up to xx% afterwards laparotomy[15] but may exist every bit high as 41% afterward aortic surgery[viii]. Most incisional hernias develop during the first months after surgery, a critical flow for the healing of transected muscular and fibrous layers of the abdominal wall; even so, 5%-10% may remain clinically silent for up to five years until detection[16].
Mostly they occur at the site of a midline or paramedian incision but they may occur at other sites of surgical interruption of soft-tissue layers[12]. A particular type of incisional hernias is parastomal hernias.
Typically, properitoneal fat or the greater omentum protrudes through the hernial defect. If the hernia is left untreated, bowel loops may exist incorporated into the hernia and become incarcerated or strangulated[12].
DIAPHRAGMATIC HERNIAS
The diaphragm, the principal muscle of respiration, is made of muscular and membranous structures. Information technology separates the thoracic and abdominal cavities to maintain the pressure level differentials in the corresponding compartments. The muscles of the diaphragm arise from the lower office of the sternum, the lower six ribs and the lumbar vertebrae of the spine and are attached to a central bleary tendon.
The central part is fibrous and consists of the phrenic heart; the bulk device is substantially muscle. The phrenic heart is shaped like a clover leaf with a front and two side portions. Fleshy bundles co-operative off from the border that fit on the inside of the chest wall, splitting into sternal, costal and lumbar bundles. The diaphragm is crossed by the esophagus and by nervus and vascular formations, through the esophageal orifice, the aortic orifice and the orifice for the transition of the inferior cava vein. Two large muscle bundles branch off from the first and 2d lumbar vertebra, the right and the left medial diaphragmatic pillars. The fundamental tendon of the diaphragm is a thin but strong aponeurosis situated near the eye of the vault formed by the muscle simply somewhat closer to the front than to the back of the thorax so that the posterior muscular fibers are the longer.
A certain poverty of muscle fibers is found on two pocket-size triangular spaces located on either side of the insertion chest and paravertebral level, posteriorly. These spaces are the points of least resistance of the diaphragmatic dome and are called, respectively, Morgagni and Bochdalek foramina. Hernias are the most mutual diseases of the diaphragm. These can be classified in hiatal hernias, either sliding or paraesophageal hiatal, and lateral. Among lateral hernias, nosotros distinguish inductive (Morgagni hernia) and posterior (Bochdalek hernia) hernias. These hernias are easily detected with conventional radiology, although they are visible on United states and especially with CT scans.
The common sliding hiatal hernia and the less common paraesophageal hernia are caused by weakened or torn phrenoesophageal membrane. Sliding hiatal hernias account for 99% of all diaphragmatic hernias, occurring in almost 10% of all adults[12]. In this hernia, the gastroesophageal junction is to a higher place the esophageal hiatus of the diaphragm. They are frequently associated with gastroesophageal reflux[12]. In a paraesophageal hernia, all or portions of the stomach herniate into the breast but the gastroesophageal junction is below the diaphragm. There is no correlation with gastro-esophageal reflux and esophagitis unless associated with a sliding hernia.
Weakening of the phrenicoesophageal membrane allows the proximal portion of the stomach to herniate through the esophageal hiatus into the chest. Every bit the hernial defect enlarges, other viscera such as the duodenum, colon, pancreas and mesenteric fat may protrude into the chest (Effigy 2E). Gastro-esophageal reflux and esophagitis are frequent and in rare cases, lung fibrosis is possible following astringent acid reflux. Complications of sliding hiatal hernias include incarceration and gastric volvulus[12].
With ultrasound, information technology is possible to meet the gastroesophageal junction, especially in children, although direct visualization of a hiatal hernia is elusive.
Bochdalek hernias have a prevalence of three%-vi%[17]. They are unremarkably congenital, resulting from matted development of the diaphragm but may exist caused as a result of surgery, trauma or infection[12]. The bulk of Bochdalek hernias (80%-85%) occur on the left side of the diaphragm (Figure 2F). A large proportion of the remaining cases occur on the correct side and a small fraction is bilateral. CT shows aperture of the posterolateral part of the diaphragm and a continuous mass above and below the diaphragm (Figure 2F)[18,19].
Morgagni's hernia is a rare type of diaphragmatic hernia, characterised by herniation through the foramina of Morgagni which is located immediately adjacent to the xiphoid process of the sternum[18]. Protrusion of liver occurs in infants and protrusion of mesenteric fatty occurs in adults. Herniation of bowel or stomach can occur in both age groups. The bulk of hernias occur on the right side of the torso and are more often than not asymptomatic[12]. In newborns, a diaphragmatic hernia can be detected on obstetric ultrasound examination and in these cases respiratory distress is expected at nascency.
Venous congestion and strangulation may occur.
INTERNAL HERNIAS
Internal hernias involve protrusion of the viscera through the peritoneum or mesentery and into a compartment in the abdominal cavity[20]. The orifices can be pre-existing ana-tomical structures, such equally foramina, recesses and fossae[xx] or built defects of the mesentery. In other cases, they
may be caused by surgery, trauma, inflammation or ische-
mic changes[xx].
Clinical symptoms, when present, may be intermittent, nonspecific and commonly include some degree of nausea, distension, epigastric discomfort and abdominal pain but likewise chronic digestive bug and recurrent, intermittent abdominal obstacle. Oftentimes they may occur with an acute abdominal obstruction of small bowel loops that develops through normal or abnormal apertures[xx]. The herniated bowel can render to its normal site or be incarcerated depending on the size of the foramina and the size of the herniated bowel[21]. Internal hernias are better diagnosed past specific sign at CT equally well as abnormal location of the small-scale bowel.
The occurrence of abdominal internal hernias is rare and according to the classification of internal abdominal herniations devised past Ghahremani[22], tin be separated in to six main groups: paraduodenal hernias (50%-55% of internal abdominal herniations), hernias through the foramen of Winslow (half dozen%-10%), transmesenteric hernias (8%-10%), pericecal hernias (10%-xv%), intersigmoid hernias (4%-8%) and paravesical hernias (< iv%)[1].
Paraduodenal hernias account for over half of reported internal hernias. They are basically built in origin, representing entrapment of small intestine beneath the mesentery of colon probably occurring due to abnormal embryological rotation of midgut and variation in peritoneal fixation and vascular folds[23]. Two types of paraduodenal hernias must exist distinguished: left-sided paraduodenal hernias and right-sided paraduodenal hernias[22]. Virtually occur on the left side (75%)[22] through the fossa of Landzert and proceed into the descending mesocolon or distal transverse mesocolon (Figure 2G). One-fourth oc-
curs on the right side through the fossa of Waldeyer and proceeds into the ascending mesocolon. Clinical manifestations of paraduodenal hernias can be quite variable from mild abdominal cramps or discomfort to symptoms of bowel obstruction[12]. Postprandial pain with postural variation is a characteristic symptom.
Left-sided paraduodenal hernias are acquired by the raising up of a peritoneal fold past the junior mesenteric vein equally it runs along the lateral side of fossa and then above information technology[1]. The small intestine may herniate through the orifice posteriorly and downwards to the left, lateral to the ascending limb of duodenum extending into descending mesocolon and left function of the transverse mesocolon. The gratis edge of hernia thus contains the inferior mesenteric vein and ascending left colic artery[21].
Radiographical findings of left-sided paraduodenal hernias are well correlated to the anatomic topography. On barium examinations, the typical finding is the presence of a mass of small-bowel loops just lateral to the fourth portion of the duodenum that is separated from the remaining bowel loops. On CT, the location of the herniated small-bowel loops is more clearly visualized, lying behind the ascending left colic artery[12] at the level of or just above and exterior to the ligament of Treitz[ane]. The inferior mesenteric vein and the ascending left colic avenue tin be seen to a higher place the herniated loop along the anterior aspect (Figure 2G). The radiologist should search for additional signs of bowel complications: obstacle, vessel engorgement, or fifty-fifty acute small-bowel ischemia, bowel-wall hyperdensity, mesenteric fluid and the presence of parietal air[24].
Right-sided paraduodenal hernias are congenital diseases that may be related to the incomplete or absent 180° rotation of the embryological intestine[1]. Right paraduodenal hernias correspond an entrapment of small-scale bowel behind the ascending mesocolon and correct one-half of transverse mesocolon. The superior mesenteric avenue and the correct colic vein are in the free edge of the hernia[23]. The typical clinical presentations of right and left-sided paraduodenal hernias are like; however, both conventional barium studies and CT can be used to distinguish betwixt the ii[1].
Internal abdominal hernias through the foramen of Winslow business relationship for 6%-10% of all internal hernias. The pocket-size bowel is the herniated viscera in threescore%-70% of cases. The terminal ileum, cecum and ascending colon are involved in about 25%-30%[20]. Other viscera such as the transverse colon, gallbladder and omentum have also been reported[22,25]. The formation mechanism of these hernias is distinct from that of paraduodenal because the foramen of Winslow is a normal peritoneal opening allowing a communication betwixt the lesser sac and the rest of the peritoneal cavity[1]. The foramen is situated in the portacaval space lying betwixt the portal vein anteriorly and the inferior vena cava posteriorly including the portal vein, mutual bile duct and hepatic artery[1].
Predisposing factors include an enlarged foramen of Winslow and excessively mobile intestinal loops because of a long mesentery or persistence of the ascending mesocolon[22,26]. Patients nowadays with astute onset of progressive upper abdominal hurting and small bowel obstruction. Physical examination usually reveals localized tenderness and distension in the epigastric regions. Radiographical features of internal abdominal herniations through the foramen of Winslow can vary depending on which of the organs are entrapped.
Transmesenteric hernias are five%-ten% of internal abdominal herniations overall and are the most common internal hernia in children (Figure three)[1]. In fact, almost 35% of those hernias occur during the pediatric menstruum due to a congenital defect in the pocket-size-bowel mesentery in the ileocecal region, while in adults, surgical procedures enhance the opening of a foramen, through which the bowel crosses[twenty]. Most occur on the right side of the greater omentum[27]. Furthermore, a high incidence of transmesenteric hernias later abdominal surgery has been described, specially subsequently the cosmos of a Roux-en-Y anastomosis[28].
Ultrasonography of transmesenteric hernia in an baby (calipers).
Clinical symptoms often include signs of acute modest-bowel obstruction[1]. Considering of the absence of a limiting hernial sac, it can often exist hard to distinguish betwixt a transmesenteric hernia and a small-bowel volvulus. Considering of the difficulty of identification, detection of a group of pocket-sized bowel loops and abnormalities of the mesenteric vessels plays an important role in diagnosis of transmesenteric hernia. CT shows that converging mesenteric vessels are located at the entrance of the hernial sac and there is displacement of the principal mesenteric trunk[29].
Pericecal hernias business relationship for but 6%-thirteen% of internal abdominal herniations[ane]. The pericecal fossa is located backside the cecum and ascending colon and is limited by the parietocecal fold outwards and the mesentericocecal fold inwards[1]. Pericecal hernias usually involve an ileal loop that goes through a defect in the cecal mesentery and occupies the pericecal fossa, especially the correct paracolic gutter[1]. Clinical symptoms are often characterized by episodes of intense lower intestinal pain, similar a colicky right lower quadrant hurting very similar to the appendiceal pain, often causing confusion[30]. Through barium or CT, pericecal hernias occur as dilated and fixed pocket-size-bowel loops located posteriorly and laterally in relationship to the cecum, oftentimes into the right paracolic gutter.
The sigmoid mesocolon is a peritoneal fold that anchors the sigmoid colon to the pelvic wall and near the left common iliac artery there is a potential site for an internal hernia[20]. Herniation of pocket-sized-bowel segments through the mesosigmoid occurs because of an incomplete defect of the mesentery. These types of internal hernias business relationship for 6% of all internal hernias and are divided into three groups: intersigmoid hernia, transmesosigmoid hernia and intermesosigmoid hernia[20].
Intersigmoid hernia, the most mutual type, is herniation into a peritoneal pocket formed between 2 adjacent sigmoid segments and their mesentery, the intersigmoid fossa[1], situated in the attachment of the lateral aspect of the sigmoid mesocolon[20].
In the transmesosigmoid hernia, the small bowel loops goes through a foramina in the sigmoid mesocolon, especially the left lower of the abdomen, posteriorly-laterally to the sigmoid colon. Intramesosigmoid hernia is incarceration with a hernial sac through a congenital defect, present in only one of the constituent leaves of the sigmoid mesentery[twenty].
Supravesical hernias, although rare, are the cause of most pelvic hernias[i]. Herniation occurs in the supravesical fossa, between the remnants of the median and the left or correct umbilical ligaments[ane,20]. Herniated bowel loops can either remain inside or extend higher up the pelvis. Internal supravesical hernias are divided into three categories: anterior, lateral, and posterior, which are based on whether the course is in front end of, beside or behind the bladder[20].
Conclusion
At that place are several situations where an accurate clinical examination may be difficult or impossible. This may be due to pain, obesity or excessive scar formation over a minor, deep peritoneal defect. Moreover, the herniated segments occasionally dissect and hide between muscular, aponeurotic and fascial layers of the abdominal wall. These interparietal or interstitial hernias often present with localized swelling and tenderness adjacent to the surgical scar but their actual content and internal orifice are seldom palpable. In all those cases, the presence of a difficult clinical examination of the hernia can be documented by gastrointestinal barium studies, sonography or CT to give the correct diagnosis[16].
Imaging studies become fundamental, peculiarly in those patients with important pain or in obese where the abundant subcutaneous fat can prevent the palpation of a deeply seated peritoneal defect and the protruding intestinal loop or greater omentum[12]. Radiological studies may so be used to visualize the herniated segments and to evaluate associated complications such as intestinal obstruction. CT sections also give the size of the defect and content of the hernia[16].
Footnotes
Peer reviewers: Kenneth Kak Yuen Wong, MD, PhD, Banana Professor, Department of Surgery, The University of Hong Kong, Queen Mary Infirmary, Pokfulam Route, Hong Kong, China
S- Editor Zhang HN 50- Editor Roemmele A E- Editor Zhang Fifty
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