Diagnosis and treatment of internal hernia after laparoscopic surgery for gastric cancer / 中华消化外科杂志

With the development of laparoscopic surgery for gastric cancer, more and more surgeons use laparoscopic techniques and even totally laparoscopic techniques in gastric cancer surgery. However, technological progress brings not only smaller trauma, but also new problems and risks. Compared with traditional open surgery, the high incidence of internal hernia after laparoscopic gastric cancer surgery is an urgent problem to be solved. As the incidence of internal hernia often occurs after discharge, patients usually choose the nearest hospital for diagnosis and treatment due to the urgent course of disease. As a result, patients with internal hernia often have serious complications due to delayed treatment because of the difficulty in diagnosis. Sometimes, there are patients even death. The authors review the relevant research on postoperative internal hernia of gastric cancer in recent years and combine with practical experience to discuss the diagnosis and treatment strategy of internal hernia after laparoscopic surgery for gastric cancer, aiming to improve the clinicians′ attention to the disease and provide reference for its diagnosis and treatment.

Hérnias internas após bypass gástrico laparoscópico em Y-de-Roux: espaços intermesentéricos, sintomas e diagnóstico / Internal hernias after laparoscopic Roux-Y gastric bypass: intermesenteric spaces, symptoms and diagnosis

Introdução: Com o aumento da prevalência mundial de obesidade, operações para redução de peso vêm sendo cada vez mais frequentes, sendo o bypass gástrico laparoscópico a principal delas. Entretanto, existem complicações associadas, dentre elas, a formação de hérnias internas. Objetivos: Revisar o bypass gástrico e o desenvolvimento de hérnias internas, e discorrer sobre a importância do uso de tomografia no diagnóstico dessa complicação. Métodos: Revisão integrativa, envolvendo 646 artigos pesquisados nas bases de dados BVS e PubMed; deles, apenas 10 respeitaram os critérios de inclusão. Resultados: Atualmente o bypass gástrico é um dos principais métodos cirúrgicos utilizados em procedimentos que visam a redução de peso em obesos. Entretanto, a formação de hérnias internas em espaços mesentéricos criados durante o procedimento é uma possibilidade e resulta em sintomas inespecíficos, podendo levar a consequências graves. Nesse contexto, a tomografia computadorizada é instrumento diagnóstico muito útil. Conclusão: Em pronto-socorro, tomografia abdominal deve ser realizada em pacientes com queixa de dor abdominal inespecífica e com histórico de bypass gástrico, pois é útil no diagnóstico precoce das hérnias internas, diminuindo sua morbimortalidade.

Introduction: With the increase in the worldwide prevalence of obesity, operations to reduce weight are becoming more frequent, with laparoscopic gastric bypass being the main one. However, there are associated complications, among them, the formation of internal hernias. Objectives: To review gastric bypass and the development of internal hernias and discuss the importance of using tomography in the diagnosis of this complication. Methods: Integrative review, involving 646 articles searched in the BVS and PubMed databases; of them, only 10 met the inclusion criteria. Results: Currently, gastric bypass is one of the main surgical methods used in procedures aimed at reducing weight in obese people. However, the formation of internal hernias in mesenteric spaces created during the procedure is a possibility and results in nonspecific symptoms, which can lead to serious consequences. In this context, computed tomography is a very useful diagnostic tool. Conclusion: In an emergency room, abdominal tomography should be performed in patients complaining of nonspecific abdominal pain and with a history of gastric bypass, as it is useful in the early diagnosis of internal hernias, reducing their morbidity and mortality.

Internal hernia after laparoscopic left colectomy: case series and review of the literature

Objective: Laparoscopic colectomy has gained acceptance as a standard treatment for benign and malignant colorectal disease, such as diverticular disease and cancer, among others. Same as in open surgery, the laparoscopic approach carries a low risk of small bowel obstruction in the postoperative period, but in laparoscopic surgery, internal hernia after laparoscopic left colectomy may be a cause of small bowel obstruction with a significant risk of morbidity and mortality. This rare complication may be prevented with routine closure of the mesenteric defects created during the colectomy. Methods: We present four cases of internal herniation after laparoscopic colectomy. Two cases were after laparoscopic left colectomy and two after laparoscopic low anterior resection. All four cases had full splenic flexure mobilization. Routine closure of the mesenteric defect was not performed in the initial surgery. Results: The four patients were treated by laparoscopic reintervention with closure of the mesenteric defect. In two of them, conversion to open surgery was necessary. One of the patients developed recurrent internal herniation after surgical reintervention with mesenteric closure of the defect. All patients were managed without need for bowel resection, and mortality rate was 0%. Conclusion Internal herniation after laparoscopic colorectal surgery is a highly morbid complication that requires prompt diagnosis and management and should be suspected in the early postoperative period. Additional studies with extended follow-up are required to establish recommendations regarding its prevention and management. (AU)

Obstrucción intestinal debido a hernia interna transmesentérica congénita en adulto / Bowel obstruction due to congenital transmesenteric internal hernia in adults

RESUMEN Las hernias internas constituyen una causa rara de obstrucción de intestino delgado. Entre estas se encuentra la hernia transmesentérica congénita, que es muy infrecuente en adultos. Presentamos el caso de un paciente de sexo masculino de 20 años, sin antecedentes quirúrgicos ni traumáticos, que acudió al Servicio de Urgencias con sintomatología de obstrucción intestinal. Se realizó laparotomía de emergencia, encontrándose intestino delgado encarcelado a través de un defecto localizado en mesenterio yeyunal distal. No había necrosis intestinal por lo que no fue necesaria la resección intestinal. El paciente evolucionó favorablemente y fue dado de alta al tercer día posoperatorio.

ABSTRACT Internal hernias are a rare cause of bowel obstruction. Congenital transmesenteric hernias, a type of internal hernias, are uncommon in adults. We report the case of a 20-year-old male patient with no history of surgeries or trauma who presented to the emergency department with symptoms of bowel obstruction. Emergency laparotomy revealed small bowel incarceration through a defect in the distal jejunal mesentery. As the bowel was viable there was no need to perform bowel resection. The patient evolved with favorable outcome and was discharged on postoperative day 3.

Internal Hernia Incarceration Mimicking Impending Rupture of an Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 68-year-old man visited a family physician with a complaint of epigastric pain lasting several hours. Computed tomography revealed an abdominal aortic aneurysm that was 60 mm in length and a small amount of ascites, resulting in a tentative diagnosis of impending rupture of the abdominal aortic aneurysm. The patient was referred to our hospital and underwent emergency surgery. Intraoperative findings ruled out rupture and inflammatory changes in the abdominal aortic aneurysm. We observed the abdominal cavity and detected an internal hernia. The 15-cm-long ileum was incarcerated by an abnormal cord between the vesicorectal fossa and peritoneum. The cord was dissected to release the internal hernia. Intestinal peristalsis and pulsation of the marginal artery were maintained, allowing us to avoid intestinal resection. The patient reported that his epigastric pain disappeared soon after surgery. On the 24th postoperative day, the patient underwent abdominal aortic replacement. Our case suggests that internal hernia incarceration is an important differential diagnosis of impending rupture of an abdominal aortic aneurysm, even in cases with no history of laparotomy.

Laparoscopic management of a small bowel obstruction: paraduodenal hernia

Paraduodenal hernia are very rare but the commonest internal hernia. Left paraduodenal hernia is due to herniation of the small bowel into the fossa of Landzert. The fossa results from a combination of failure of fusion of the small bowel mesentery with the retro peritoneum and malrotation of the midgut. Here we present a 27 years lady who saw multiple consultants with varied presentations and underwent extensive investigations over a one-year period, with one consultant referring her to a psychiatrist for malingering. CT scan revealed a foramen of Winslow hernia. The radiologist has to be aware of the CT findings of this unusual hernia. At laparoscopy, it was a left paraduodenal containing small bowel. We reduced the contents and plicated the sac with closure of the mouth. Patient did well and was discharged on 3rd post-operative day. On follow up she is doing well.

Laparoscopic management of left paraduodenal hernia: a rare case report

An internal hernia is any protrusion of a solid organ or a hollow viscus through a defect within the abdominal cavity. Paraduodenal hernias are rare, but are the most common variety of internal hernias. We present a rare case of a left sided paraduodenal hernia in a 26 years old otherwise healthy male who presented in emergency department with intermittent colicky upper abdominal pain. Left paraduodenal hernia was diagnosed pre operatively in a computer tomography scan. Hence patient was offered a laparoscopic repair. Our search via online search engines revealed very few case reports of Paraduodenal hernias which were repaired laparoscopically. We believe that in expert hands, paraduodenal hernias should be managed with laparoscopic technique as it significantly reduces morbidity and hospital stay.

Rare case of paracaecal hernia with intussusception presenting as small bowel obstruction: case report

Primary internal hernias are very rare in adults. They are an unusual cause of small intestinal obstruction and lead to high morbidity and mortality if left untreated. Clinical presentation of internal hernia is highly nonspecific. Imaging has limited role in diagnosing the cause of acute intestinal obstruction. Internal hernias are usually detected at laparotomy. We report a case of a 61-year-old male who presented with acute intestinal obstruction which was attributed later to a very rare type of internal hernia on exploratory laparotomy. A loop of ileum was found to enter the retroperitoneum through a hernia gate which was located lateral to the caecum and ileo ileal intussusception was noted proximal to the herniated loop. The segment of intestine was resected and anastamosed then hernial defect was closed. Paracaecal hernias are the rare type of hernias in internal hernia. In our case, intussusception was noted proximal to the herniated ileal loop which is a very rare presentation. Intussusception was reported previously with paraduodenal type. One should always keep in mind while conducting emergency laparotomy, internal hernias can be a cause for intestinal obstruction.

Hernia interna estrangulada por plastrón en el tercio distal del apéndice cecal. Reporte de un caso / Internal Hernia Strangulated by Plastron in the Distal Third of the Cecal Appendix. Case Report

Resumen Las hernias internas son causa infrecuente de obstrucción intestinal con una incidencia del 0.2-0.9%, por lo que su diagnóstico temprano representa un reto. El órgano más frecuentemente herniado es el intestino delgado, lo que confiere un gran espectro de síntomas, desde dolor abdominal ligero hasta datos de abdomen agudo1,2. Se presenta el caso de una paciente de 8 años de edad con sintomatología digestiva inespecífica; se realizó diagnóstico transoperatorio en el que se encontró hernia interna estrangulada por plastrón en el tercio distal del apéndice. Se realizó apendicectomía y a los cuatro días se dio de alta sin complicaciones.

Abstract Internal hernias are an infrequent cause of intestinal obstruction with an incidence of 0.2-0.9%, therefore their early diagnosis represents a challenge. The most frequently herniated organ is the small bowel, which results in a wide spectrum of symptoms, varying from mild abdominal pain to acute abdomen1,2. We present the case of an eight-year old patient with nonspecific digestive symptoms, a transoperative diagnosis was made in which an internal hernia was found strangulated by plastron in the distal third of the appendix. Appendectomy was performed and four days later the patient was discharged without complications.

Intestinal obstruction in case of internal hernia through congenital defect in falciform ligament in adult

Small bowel obstruction due to internal herniation of ileum through congenital defect in falciform ligament is exceedingly rare, about 0.2% such cases of hernia through congenital defect in falciform ligament have been reported. The case presentation of 60 year old male patient present in surgery department with acute abdominal pain since 7 days. Based on clinical assessment and radiological evidence, intestinal obstruction was diagnosed. For which patient underwent exploratory laprotomy. The discussion of Intraoperative a loop ileum was found obstructed in congenital defect in falciform ligament. Obstruction was relieved by division of leaf of defect, without the need of intestinal resection.

Analysis of abdominal internal hernia with main manifestation of metabolic acidosis / 中国中西医结合急救杂志

Abdominal internal hernia is relatively rare in clinics, which is easily to be ignored and occur serious complications, mainly the obstruction of gastrointestinal tract, such as gastrointestinal ischemia and necrosis, that could be life-threatening. This article introduced one case with atypical abdominal pain as the first manifestation of the disease, then the main symptom was metabolic acidosis and treatment was carried out, and finally by surgery the diagnosis of abdominal internal hernia was confirmed and proper treatment given.

Chylous Ascites Following Bariatric Surgery Report of Two Cases

Chylous ascites is a rare complication following bariatric surgeries. Little data is available regarding chylous ascites following bariatric surgeries per se or in association with internal hernias. Herein we present two cases of chylous ascites following Roux-En-Y gastric bypass; the first one is a 60-year-old male who was presented to the ER six months after a gastric bypass operation suffering from abdominal pain, CT scan and upper endoscopy were normal, however chylous ascites and internal hernia were found during exploratory laparoscopy. The second case is a 39-year-old female patient who was admitted three years following the gastric bypass operation and diagnosed to have small bowel obstruction due to internal hernia, and during exploratory laparoscopy a chylous ascites was found.

Internal Hernia through a Defect in the Broad Ligament of Uterus: Laparoscopic Management Using a Self-Anchoring Barbed Suture

The occurrence of internal hernia through a defect in the broad ligament is a very rare condition, which may cause small bowel obstruction. This is a case of a 50-year-old woman who developed intestinal obstruction induced by internal hernia and who had undergone laparoscopic myomectomy 7 years prior to visiting our emergency room. Abdominopelvic computed tomography showed luminal narrowing of the ileum and dilatation of the pelvic loop of the small bowel at the left side of the uterus. We detected internal hernia through the defect in the broad ligament and managed it successfully by performing a laparoscopic procedure using a barbed suture, V-Loc (Covidien, Mansfield, MA).

Postoperative internal hernia of gastric cancer:analysis of formation reasons and clinical diagnosis and treatment / 中国医师进修杂志

Objective@#To explore the reasons and clinical treatment process of postoperative internal hernia in cases of gastric cancer, and improve the diagnosis and treatment level postoperative acute abdomen pain of gastric cancer patients.@*Methods@#A retrospective analysis was carried out to study the data of clinical diagnosis and treatment in 7 patients, who were performed an emergency operation within the First Affiliated Hospital of Soochow University from January, 2013 to August, 2016 caused by postoperative internal hernias of gastric cancer.@*Results@#Among the 7 postoperative gastric cancer patients, 2 cases had taken surgery of radical full gastric resection, 3 cases had taken surgery of radical distal gastric resection, and 2 cases had taken surgery of radical proximal gastric resection. All the 7 cases were confirmed to be incarcerated intestinal obstruction caused by internal hernia during emergency operation. Only 1 case was diagnosed to be internal hernia before surgery, while 3 cases were diagnosed as volvulus, 2 cases were diagnosed as perforation and 1 case was diagnosed as gastrolplegia. The small intestinal obstruction of all cases was caused by incarcerated intestinal. All the patients recovered well, and no complications occurred.@*Conclusions@#Internal hernias of the postoperative gastric cancer patients, which is often characterized by small intestinal obstruction symptoms, is difficult to diagnose before operation. Emergency operation in time for the postoperative gastric cancer patients with continuous acute abdominal pain may help to reduce the severe complications and improve patient′s prognosis.

Cierre de brechas mesentéricas en bypass gástrico laparoscópico / Mesenteric defects closure in laparoscopic gastric bypass

Resumen El bypass gástrico laparoscópico es uno de los procedimientos bariátricos más frecuentes realizados en el mundo. Una de sus complicaciones postoperatorias es la hernia interna. Este tipo de hernias se produce como resultado de una protrusión de intestino delgado a través de los defectos mesentéricos. Esta complicación quirúrgica puede causar obstrucción intestinal, isquemia y perforación, llevando a la muerte. El cierre de los defectos mesentéricos puede tener como resultado menor incidencia de hernias internas, pero la evidencia no es categórica y el cierre podría estar asociado a complicaciones serias como sangramiento y filtración anastomótica. Aun más, el cierre podría llevar a mayor posibilidad de estrangulación del asa de intestino delgado.

Abstract Laparoscopic Gastric Bypass is one of the most frequent bariatric procedures done around the world. One of its postoperative complications are internal hernias. This kind of hernias are caused by the protrusion of a small bowel portion through mesenteric defects. This surgical complication may cause small bowel obstruction, ischemia and perforation causing death. Mesenteric defects closure may decrease the incidence of internal hernias but the evidence is not categoric and mesenteric closure might be associated to major complications like bleeding and anastomosis leaks. Even more, deficient mesenteric closure may be the cause of small bowel strangulation related to internal hernias.

MSCT diagnosis of adhesive abdominal internal hernias and its complication of strangulated intestinal necrosis / 实用放射学杂志

Objective To explore the MSCT characteristics of adhesive abdominal internal hernias and its complication of strangulated intestinal necrosis.Methods The CT data of 21 cases with adhesive abdominal internal hernias proved by operation were analyzed retrospectively.Raw data of CT images were reconstructed with MPR and/or CTA procedure for visualizing the hernia ring, intestinal mesentery and ansa interstinalis.Results Adhesive bands (hernia ring), crowding of distended and fluid-filled bowel loops with an abnormal location was visualized in 19 cases, among which the transitional segment from stenosis to dilation of the intestine was visualized in 17 cases.The crowded and engorged mesenteric vessels, edematous mesentery were visualized in 17 cases,among which mesenteric torsion was visualized in 11 cases.Varying amounts of ascites was visualized in 15 cases.All adhesive abdominal internal hernias in our study were classified according to their image manifestation.Dilated intestinal loop with thickened bowel wall was classified to type Ⅰ (7 cases).Dilated intestinal loop with normal bowel wall was classified to type Ⅱ (9 cases).Normal size of the intestinal loop with thickened bowel wall was classified to type Ⅲ (5 cases).The difference of CT values of the intestinal wall on non-contrast CT,enhancement CT values in arterial and portal phase of contrast-enhanced CT among three types of adhesive abdominal internal hernias showed statistical significance (P0.05).8 cases of adhesive abdominal internal hernias were accompanied by intestinal necrosis (5 cases for type Ⅰ,3 cases for type Ⅲ).The necrotic intestine loop manifested as markedly thickened and blurred bowel wall with reduced enhancement, while thrombosis embolism of SMV was visualized in 4 cases and thrombosis embolism of SMA in 3 cases,respectively.Massive ascites was visualized in 8 cases.Conclusion The adhesion bands,transitional segment of small intestine,gathered and translocated intestinal loops are the clue to the diagnosis of adhesive abdominal internal hernias.Edema of mesentery, gathered and engorged mesenteric vessels, occlusion of SMV or SMA and the conspicuously thickened bowel wall with reduced enhancement are the image characteristics of intestinal necrosis.

Hernia transmesentérica. Revisión del tema a raíz de un caso exótico de infarto intestinal en un adulto / Transmesenteric hernia. A literature review following an exotic case of intestinal infarction in an adult / Hérnia transmesentérica. Revisão do tema a raiz de um caso exótico de enfarte intestinal num adulto

Introducción: la hernia transmesentérica (HT) es una causa extremadamente rara de isquemia intestinal en adultos, con pocos casos reportados en la literatura. Presentación del caso: un hombre de 71 años presentó dolor epigástrico severo de seis horas de evolución, sin signos de obstrucción intestinal ni historia de cirugías abdominales previas. Ante el deterioro clínico se hizo una laparotomía que reveló un defecto transmesentérico de 4 cm en el yeyuno y herniación de ciento noventa cm de intestino delgado con signos de gangrena. Se efectuaron reducción del contenido, resección intestinal y anatomosis primaria. La recuperación fue exitosa y fue dado de alta diez días después del ingreso. Discusión: los síntomas clínicos, los estudios radiológicos y los datos de laboratorio suelen ser inespecíficos para el diagnóstico de HT. La tasa de mortalidad puede superar el 50 %. Este artículo resume las características clínicas más importantes a partir de una revisión exhaustiva de la literatura. Conclusión: la obstrucción intestinal por HT es una condición potencialmente letal. Los signos y síntomas clínicos relacionados con HT exigen un estricto seguimiento. Si no hay mejoría o se presenta deterioro clínico, se debe hacer una cirugía temprana con el fin de reducir la mortalidad y la morbilidad por esta causa.

Introduction: Transmesenteric hernia (TH) is an extremely rare cause of bowel ischaemia in adults with few reported cases. Case report: A 71-year-old man experienced six hours of severe epigastric abdominal pain, without signs of intestinal obstruction and with no history of abdominal surgery. In response to clinical deterioration, an emergency laparotomy was performed, revealing a 4 cm transmesenteric defect in the jejunal region. One hundred ninety centimeters of the small bowel were herniated through the defect and became gangrenous. The hernia was reduced, small bowel resected, and primary anastomosis performed. The patient recovered and was discharged ten days later. Discussion: Clinical symptoms, radiological imaging, and laboratory tests can be non-specific in the diagnosis of TH. The mortality rate is higher than 50 %. This paper summarizes the most important clinical traits based on a comprehensive literature review. Conclusion: Intestinal obstruction due to TH is a potentially lethal condition. The important clinical traits related to TH should be closely monitored. If there is no improvement or clinical deterioration occurs, it is mandatory to do early surgery to reduce morbidity and mortality.

Introdução: a hérnia transmesentérica (HT) é uma causa extremamente rara de isquemia intestinal em adultos, com poucos casos reportados na literatura. Apresentação do caso: um homem de 71 anos apresentou dor epigástrico severo de seis horas de evolução, sem signos de obstrução intestinal nem cirurgias abdominais prévias. Ante a presença de deterioração clínica se fez uma laparotomia que revelou um defeito transmesentérico de 4 cm no jejuno e rupturas de cento noventa cm de intestino delgado com signos de gangrena. Efetuaram-se redução do conteúdo, resseção intestinal e anastomoses primária. A recuperação foi exitosa e foi cadastrado dez dias depois do rendimento. Discussão: os sintomas clínicos, os estudos radiológicos e os dados de laboratório costumam ser inespecíficos para o diagnóstico de HT. A taxa de mortalidade pode superar 50 %. Este artigo resume as características clínicas mais importantes a partir de uma revisão exaustiva da literatura. Conclusão: a obstrução intestinal por HT é uma condição potencialmente letal. Os signos e sintomas clínicos relacionados com HT exigem um estrito seguimento. Se não há melhoria ou se apresenta deterioração clínica, deve-se fazer uma cirurgia temporã com o fim de reduzir a mortalidade e a morbilidade por esta causa.

Internal hernia of the Broad Ligament leading to acute intestinal obstruction: a case report.

Acute intestinal obstruction is a frequently encountered surgical emergency but cases arising from internal herniation through the broad ligament are very rare. We report a case of a middle aged lady with intestinal obstruction due to internal herniation of small bowel through the right side of broad ligament and managing her successfully by timely and immediate surgical intervention.

Left paraduodenal hernia accompanying chylous ascites

Paraduodenal hernia is by far the most common form of congenital internal hernia. Chylous ascites is an accumulation of lymphatic fluid in the peritoneal cavity. It develops when the lymphatic system is disrupted due to traumatic injury or obstruction. A 40-year-old, woman showed up to the Emergency Department with severe, colicky abdominal pain. Tenderness and rebound tenderness were observed at the left abdomen. Abdominal CT confirmed a cluster of dilated proximal small bowel loops with ischemic change, without ascites. The patient underwent an emergency surgery to relieve bowel ischemia. As soon as the peritoneum was exposed, 1.5 L of chylous fluid was found. A hernial sac was found along the posterior side of the mesentery of the inferior mesenteric artery. We resected the hernial sac and pulled out the herniated small bowel. On the sixth day after the surgery, she was discharged without any complication.

Left Paraduodenal Hernia: Case Report and Literature Review

An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Although they are considered as a rare cause of intestinal obstruction, para-duodenal hernias are the most common type of congenital internal hernias. We report one such case of a left para-duodenal hernia presented as acute intestinal obstruction.