Functional 3DVR imaging of abdominal wall hernias.

The purpose of this illustrative pictorial series is to demonstrate the value of an image technique known as 3D Volume Rendering (3DVR) for the pre-operative visualization and assessment of complex abdominal hernias. A small subset of complex abdominal hernia cases were selected from our early clinical experience with 3DVR to illustrate the value of visualizing standard 2D computed tomography (CT) data from a 3D perspective. For the surgeon, pre-operative 3DVR can assist the holistic understanding of abdominal hernias and any associated fascial defects, unsuspected additional hernias, dysfunctional abdominal wall bulges/eventrations, muscle denervations or atrophic changes, mesh placements, other post-surgical changes such as scarring, and relevant skeletal changes. For the patient, 3DVR provides an easily grasped understanding of the relevant anatomy, the nature of the problem at hand, and the scale of the surgical challenge. Images of this kind can help the surgeon to more effectively manage unrealistic patient expectations or explain dysfunctional bulges that do not require surgery. A functional 3DVR approach to pre-operative imaging can provide the surgeon with a more complete understanding of any hernia defect and the relevant background status of the abdominal wall in general. This can be useful in planning a more effective operative approach and help to improve surgical outcomes.

Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS))-Part A.

In 2014, the International Endohernia Society (IEHS) published the first international "Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias." Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. METHODS: For the development of the original guidelines, all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based Medicine. For the present update, all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne), the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. RESULTS: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques-minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite insufficient evidence with respect to these new techniques, it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. CONCLUSION: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initial guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.

Left paraduodenal hernia incidentally diagnosed during operation for transverse colon cancer.

We report the case of a patient with paraduodenal hernia diagnosed incidentally during an operation for transverse colon cancer. The patient was a 77-year-old woman who complained of dizziness. Laboratory data revealed no abnormal findings except slight anemia. Barium enema and colonoscopic examination revealed an irregular surfaced mass, about 5.0 cm in size, located near the flexure of the spleen of the transverse colon. A biopsy of the mass was performed, and a moderately differentiated adenocarcinoma was diagnosed. In April 2009, following the diagnosis of transverse colon cancer, laparotomy was performed, which revealed that a few loops of the jejunum were herniated through the orifice into the space posterior to the transverse mesocolon. Moreover, the jejunal loops were located right between a shifted left branch of the middle colic artery and ascending left colic artery. There were no ischemic changes in the jejunum. These findings were consistent with a left paraduodenal hernia associated with transverse colon cancer. The scheduled left hemicolectomy was performed in addition to a radical operation of the left paraduodenal hernia. The abdominal computed tomography (CT) images were reviewed postoperatively. The scan projection radiogram obtained by CT revealed a packing of jejunal loops in the middle of the abdomen. Abdominal CT revealed ascending left colic artery at the left edge of a packing of jejunal loops. The patient was discharged from our hospital 14 days after the surgery without any complications. Left paraduodenal hernias are rare and constitute less than 0.4% of all intestinal obstructions. Retrospectively reviewed, the preoperative CT is suggestive. In addition to the packing of jejunal loops in the middle of the abdomen, ascending left colic artery was clearly observed at the left edge of the packing of jejunal loops, which indicates left paraduodenal hernia.

Perineal hernia.

Abdominal wall hernias are a common abdominal pathology with higher prevalence in our population. It is usually asymptomatic but complications such as strangulation, incarceration or bowel obstruction need early detection and emergency surgery. The purpose of this article is to describe the infrequent type of hernia, illustrate the imaging findings and review the differential diagnosis. A 76-year-old woman was admitted in the emergency room with abdominal pain, vomits and diarrhoea. At her admission, a colonoscopy was attempted to perform but it was not possible to go beyond the stenosis. A barium enema and a multi-detector computed tomography (MDCT) were performed revealing a large mass in the left ischiorectal fossa, containing herniated loops of sigmoid colon adjacent to rectum. Abdominal wall hernias occur at areas of congenital or acquired weakness in the abdominal wall and are considered external hernias. MDCT is essential to identify wall hernias, make an accurate diagnosis and help for its clinical assessment. Knowing the radiological features of various types of abdominal hernias on MDCT and barium-enhanced radiographs allows confident diagnosis of these pathologies.

Combined transmesocolic and left paraduodenal hernia: barium, CT and MRI features.

Internal hernia is difficult to diagnose clinically because the symptoms are often non-specific. Although this entity is an uncommon cause of small-bowel obstruction, prompt diagnosis is essential for a favorable outcome. We report the barium, CT and MRI features of a rare case of non-obstructing combined transmesocolic and left paraduodenal hernia.

Radiological evaluation of internal abdominal hernias.

An internal abdominal herniation is the protrusion of a viscus through a normal or abnormal mesenteric or peritoneal aperture. Internal abdominal herniations can either be acquired through a trauma or surgical procedure, or constitutional and related to congenital peritoneal defects. Paraduodenal hernias are the most common type of internal abdominal hernias, accounting for over one-half of reported cases, and thus are a significant clinical entity. Other internal hernias include pericecal, transmesenteric, transomental, intersigmoid, supravesical hernias and herniation through the foramen of Winslow. Because internal abdominal herniations are rare, their diagnosis remains a challenge for both the clinician and the radiologist. Symptoms of internal abdominal herniations are nonspecific. We present our experience with the radiological evaluation of internal abdominal herniations and review the main radiologic findings on barium as well as computed tomography studies.