Cecal internal hernia through Winslow's hiatus.

BACKGROUND: Hernia through Winslow's hiatus, known as Blandin's hernia, a rare but potentially life-threatening condition, represents a diagnostic and therapeutic challenge. This case report describes a successful laparoscopic approach to a cecum hernia through the foramen of Winslow in a 63-year-old female. CASE PRESENTATION: The patient presented with 24 hours of abdominal pain and nausea. Abdominal CT scan revealed a herniated cecum and terminal ileum compressing the gastric chamber and portal vein, leading to periportal edema. Laparoscopic right colectomy was performed after successful colon content evacuation via the greater gastric curvature to facilitate reduction. This was done to aid in reduction, as there were indications of non-viability in the right colon. The procedure unfolded without complications. The patient developed postoperative abdominal collections requiring percutaneous drainage but recovered well and was discharged within two weeks. CONCLUSION: This case highlights the value of laparoscopy in managing foramen of Winslow hernias, offering minimally invasive benefits. Early diagnosis through imaging tools like CT is crucial for prompt surgical intervention and preventing complications like intestinal ischemia or perforation.

Antecedentes: La hernia por hiato de Winslow, conocida como hernia de Blandin, una afección rara pero potencialmente mortal, representa un desafío diagnóstico y terapéutico. Este informe de caso describe un abordaje laparoscópico exitoso de una hernia de ciego a través del agujero de Winslow en una mujer de 63 años. Presentación del caso: El paciente presentó dolor abdominal y náuseas de 24 horas de evolución. La tomografía computarizada abdominal reveló una hernia de ciego y íleon terminal que comprimía la cámara gástrica y la vena porta, lo que provocaba edema periportal. La colectomía derecha laparoscópica se realizó después de una evacuación exitosa del contenido del colon a través de la curvatura gástrica mayor para facilitar la reducción. Esto se hizo para ayudar en la reducción, ya que había indicios de inviabilidad en el colon derecho. El procedimiento se desarrolló sin complicaciones. El paciente desarrolló colecciones abdominales posoperatorias que requirieron drenaje percutáneo, pero se recuperó bien y fue dado de alta a las dos semanas. Conclusión: Este caso resalta el valor de la laparoscopia en el manejo del foramen de las hernias de Winslow, ofreciendo beneficios mínimamente invasivos. El diagnóstico temprano mediante herramientas de imagen como la tomografía computarizada es crucial para una intervención quirúrgica rápida y prevenir complicaciones como isquemia intestinal o perforación.

Congenital Mesenteric Defect with Transmesenteric Hernia in Children: A Case Series.

ABSTRACT: Transmesentric hernias are a type of internal hernia, in which there is herniation of bowel loops through a defect in the mesentery. They present with a wide variety of symptoms without any specific radiological features, leading to a delay in diagnosis and high mortality rate. Here, we present a case series of four patients with this rare but fatal cause of small bowel obstruction. Three children presented to the emergency department with small bowel obstruction. The other baby was a preterm neonate with an antenatal scan showing small bowel obstruction. All children underwent emergency laparotomy and were found to have a mesenteric defect with herniation and gangrene of the small bowel. Resection anastomosis of the gangrenous segment and closure of the mesenteric defect were done. The differential for small bowel obstruction in children should include transmesentric hernia. Laboratory or imaging investigations are often inconclusive. Timely exploration can save lives in this rare but life-threatening condition.

[Strangulated hernia of the foramen of Winslow complicated by acute colonic obstruction]. / Ushchemlennaya gryzha Vinslova otverstiya, oslozhnennaya ostroi tolstokishechnoi neprokhodimost'yu.

Internal hernias, in particular, hernia of the foramen of Winslow, are rare and occur in typical sites. Laparotomy is common in these cases while laparoscopic surgery is rarely used in such urgent cases. However, modern diagnosis and treatment including computed tomography and laparoscopy allowing minimally invasive interventions are not an exception for patients with hernia of the foramen of Winslow. This approach is effective for this problem and prevents adverse outcomes of disease.

Transmesenteric internal hernia: an unexpected adverse event induced by colonoscopy.

Transmesenteric internal hernia is an uncommon cause of small bowel obstruction that occurs when small bowel loops protrude through a mesenteric defect into the abdominal cavity. Herein, we present an unexpected case of colonoscopy-induced transmesenteric internal hernia. An 81-year-old male patient presenting with intermittent hematochezia and constipation had undergone a laparoscopic left nephrectomy for ureteral cancer. A colonoscopy was performed to identify the etiology of his symptoms. He complained of severe abdominal pain 2 h after the examination despite uneventful endoscopic procedures, including cold snare polypectomy. Contrast-enhanced computed tomography revealed a strangulated small bowel obstruction with a closed-loop formation outside the descending colon. The small bowel loop was incarcerated into the left retroperitoneal space. Emergency laparotomy detected small bowel loops that prolapsed into the nephrectomy pedicle via a descending mesenteric defect, developed during the laparoscopic left nephrectomy. The incarcerated small bowel was detached from the hernia and returned to its normal position, and the mesenteric defect was closed. He demonstrated an uneventful postoperative course, with no internal hernia recurrence after discharge. This case indicates the risk of transmesenteric internal hernia through inadvertently created mesenteric defects should be borne in mind, especially when performing colonoscopies in patients who underwent laparoscopic nephrectomies.

A novel technique for NO.253 lymph node dissection and left colic artery preservation to avoid potential postoperative internal hernia in laparoscopic radical resection for rectal cancer.

BACKGROUND: The preservation of the left colic artery (LCA) has emerged as a preferred approach in laparoscopic radical resection for rectal cancer. However, preserving the LCA while simultaneously dissecting the NO.253 lymph node can create a mesenteric defect between the inferior mesenteric artery (IMA), the LCA, and the inferior mesenteric vein (IMV). This defect could act as a potential "hernia ring," increasing the risk of developing an internal hernia after surgery. The objective of this study was to introduce a novel technique designed to mitigate the risk of internal hernia by filling mesenteric defects with autologous tissue. METHODS: This new technique was performed on eighteen patients with rectal cancer between January 2022 and June 2022. First of all, dissected the lymphatic fatty tissue on the main trunk of IMA from its origin until the LCA and sigmoid artery (SA) or superior rectal artery (SRA) were exposed and then NO.253 lymph node was dissected between the IMA, LCA and IMV. Next, the SRA or SRA and IMV were sequentially ligated and cut off at an appropriate location away from the "hernia ring" to preserve the connective tissue between the "hernia ring" and retroperitoneum. Finally, after mobilization of distal sigmoid, on the lateral side of IMV, the descending colon was mobilized cephalad. Patients'preoperative baseline characteristics and intraoperative, postoperative complications were examined. RESULTS: All patients' potential "hernia rings" were closed successfully with our new technique. The median operative time was 195 min, and the median intraoperative blood loss was 55 ml (interquartile range 30-90). The total harvested lymph nodes was 13.0(range12-19). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 8.0 days. One patient had an injury to marginal arterial arch, and after mobolization of splenic region, tension-free anastomosis was achieved. No other severe postoperative complications such as abdominal infection, anastomotic leakage, or bleeding were observed. CONCLUSIONS: This technique is both safe and effective for filling the mesenteric defect, potentially reducing the risk of internal hernia following laparoscopic NO.253 lymph node dissection and preservation of the left colic artery in rectal cancer surgeries.

Double Internal Hernia: Laparoscopic Resolution.

Gastric bypass surgery is a common and effective procedure for obesity and associated comorbidities. However, long-term complications, such as internal hernias, can pose diagnostic and therapeutic challenges. Internal hernias after gastric bypass are rare but can lead to severe complications, including volvulus and bowel ischemia. Understanding the anatomical variations and employing laparoscopic techniques for resolution are crucial in managing these cases.

Meticulous Closure of Mesenteric Defects Effectively Reduces the Incidence of Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass.

INTRODUCTION: Internal hernia (IH) after Roux-Y gastric bypass (RYGB) can lead to extended small bowel ischemia if it not recognized and treated promptly. The aim of this study is to show whether improvement in mesenteric defect (MD) closure reduces the incidence of IH. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data from our database including all patients who underwent laparoscopic RYGB between 1999 and 2015. The usual technique was a retrocolic/retrogastric RYGB. We divided patients in four groups according to the closure technique for MD and compared incidences of IH between groups. All patients had at least 8 years of follow-up. RESULTS: A total of 1927 patients (1497 females/460 males, mean age of 41.5 ± 11 years) were operated. A retrocolic/retrogastric RYGB was performed in 1747 (90.7%) and an antecolic RYGB in 180 patients. Mean duration of follow-up was 15 (8-24) years. 111 patients (5.8%) developed IH, the majority through the jejunojejunostomy (JJ, 3.7%) and Petersen (1.7%) defects. With improvement of closure technique, the incidence decreased over time, from 12.9% in the group with separate sutures to 1.05% in the most recent group with running non-absorbable sutures and an additional purse-string at the JJ defect (p < 0.0001). CONCLUSION: Meticulous closure of MD during RYGB is a very important step that significantly reduces the IH risk after RYGB, even with a retrocolic/retrogastric anatomy. Using running non absorbable braided sutures and an additional purse-string suture at the JJ is the most effective technique, but a small IH risk persists. A high index of suspicion remains necessary in patients who present with acute abdominal pain after RYGB.

Internal hernia through the Treitz fossa after robotic pancreatoduodenectomy: pathogenesis and preventive measures.

Internal hernia through the Treitz fossa following robotic pancreatoduodenectomy is a rare but potentially serious complication. In our review of 328 cases of robotic pancreatoduodenectomies, two patients (0.6%) required repeat surgery due to internal herniation of the entire small bowel through the Treitz fossa. This complication can present as afferent loop syndrome, with symptoms including nausea, vomiting, and abdominal distension, possibly leading to cholangitis and pancreatitis. Timely diagnosis and intervention are paramount, as conservative management often fails. Preventive measures involve closing the peritoneal defect in the Treitz fossa at the end of robotic pancreatoduodenectomy, particularly in lean patients with thin mesentery who are at increased risk of internal hernia due to increased mobility of the small bowel. This technical note elucidates the pathogenesis of Treitz hernia following robotic pancreatoduodenectomy and underscores the importance of closing the peritoneal breach to prevent this rare yet potentially serious complication.

A case study of an acute internal hernia: The complex diagnostic challenges of Roux-en-Y gastric bypass complications.

ABSTRACT: Obesity remains a global health challenge linked to several comorbidities, such as obstructive sleep apnea, hypertension, hyperlipidemia, and diabetes. The prevalence of bariatric surgeries being performed is steadily increasing because it is a highly effective surgical tool used to achieve significant permanent weight loss. However, with all weight loss surgeries, several complications may not present for months to years after the initial procedure. In particular, the anatomical changes that occur after the Roux-en-Y gastric bypass (RNYGB) make the risk of internal hernias high. This particular complication is rare but lethal if unrecognized and not treated promptly. This clinical case study aims to provide readers with an overview of diagnosing and recognizing an internal hernia in the setting of previous laparoscopic RNYGB surgical history. Because of the sheer increase in the volume of patients undergoing bariatric surgery worldwide, health care providers must be well educated on the insidious presentations of this late complication and be prepared to act quickly to diagnose and treat these acute abdomen scenarios.

A Rare Case of Small Bowel Obstruction in a 15-Year-Old Girl: Internal Hernia Associated with Meckel's Diverticulum.

BACKGROUND Meckel's diverticulum is a congenital remnant of the omphalomesenteric duct and is the most common congenital gastrointestinal malformation. Most patients are asymptomatic, but a rare presentation is with subacute small bowel obstruction (SBO) due to herniation of bowel loops through an internal hernia formed by the Meckel's diverticulum and adjacent mesentery that forms an internal hernia. This report is of a 15-year-old girl presenting as an emergency with vomiting and small bowel obstruction due to an internal hernia associated with Meckel's diverticulum. CASE REPORT We present a case of a 15-year-old girl who presented to the Children's Emergency (CE) department with persistent vomiting and abdominal distension and tenderness. X-rays demonstrated dilated small bowel loops, prompting admission under Pediatric Surgery (PAS). A subsequent computed tomography (CT) scan was performed, which demonstrated multiple dilated small bowel loops, confirming SBO, and a blind-ending "C-shaped" bowel loop at the region of the terminal ileum. A diagnostic laparotomy was performed, which confirmed the presence of a Meckel's diverticulum. The tip of the Meckel's diverticulum was adherent to part of the small bowel mesentery, forming an internal hernia defect through which a loop of proximal ileum had herniated, resulting in SBO. She then underwent a laparoscopy-assisted transumbilical Meckel's diverticulectomy (LATUM). The patient recovered uneventfully and was discharged on the 4th postoperative day. CONCLUSIONS In children presenting with SBO, the possibility of Meckel's diverticulum as an etiology should be considered as a differential diagnosis. Early diagnosis and prompt intervention will improve clinical outcomes and avoid complications.

[A Case of Intestinal Obstruction Due to an Internal Hernia in the Mesenteric Defect after Laparoscopic Resection of Transverse Colon].

72-year-old man who was diagnosed with transverse colon cancer cT3N1aM0, Stage Ⅲb, and underwent laparoscopic- assisted resection of the transverse colon. Postoperatively, the patient was discharged from the hospital after 24 days due to complications such as paralytic ileus and intra-abdominal abscess caused by prolonged intestinal congestion. On postoperative day 91, the patient developed abdominal pain and vomiting at home, and was rushed to our hospital on the same day. Abdominal CT showed that an internal hernia had formed in the mesenteric defect after resection of the transverse colon, which was suspected to have caused obstruction of the small intestine. After adequate preoperative decompression of the intestinal tract, a laparoscopic surgery was performed on the 9th day. The operative findings were that the jejunum(100- 160 cm from the Treitz ligament)had strayed into the mesenteric defect of the transverse colon, resulting in an internal hernia. After the internal hernia was repaired laparoscopically, the mesenteric defect was closed with a 3-0 V-Loc(non- absorbable). The patient had a good postoperative course and was discharged home 6 days after surgery.

[A case of abdominal internal hernia through the foramen of Winslow in a pediatric emergency department].

Abdominal internal hernia is a rare cause of intestinal obstruction in pediatric emergency departments, being the herniation through the foramen of Winslow an exceptional entity (less than 0.5% of the herniae). We report the case of a 15-year-old adolescent male without previous surgical interventions who presented with abdominal pain and vomiting; computed tomography scans showed intestinal obstruction due to an internal hernia through the foramen of Winslow. To reduce the herniated ileum, the patient required surgical intervention with diagnostic laparoscopy, which, due to bad visualization, was changed to supraumbilical midline laparotomy. There was no need to resect the affected ileum as it appeared healthy. We did not perform a preventive technique to reduce the risk of recurrence. Postoperative pelvic collection was conservatively managed with antibiotics. The patient undergoes regular follow-up in the pediatric surgery department.

Quality of stapled mesenteric defect closure influences the chance of reopening after laparoscopic Roux-en-Y gastric bypass surgery.

Internal herniation (IH) is a common problem after laparoscopic Roux-en-Y gastric bypass surgery (RYGB). Routine closure of the mesenteric defects (MDs) reduces the risk of IH. Only very few articles report on risk factors for IH or describe detailed closing techniques. There is no consensus yet on the best closing method. The objective of this study is to determine the optimal stapling method for closure of MDs after RYGB. All performed RYGB procedures in our high-volume bariatric institute were included. Quality of the closure was scored in the categories poor, sub-optimal, and optimal, to see if the quality of the closure would predict the chance of reopening of the MDs and, therefore, the chance of IH. During any type of laparoscopy in the follow-up of the patient, the conditions of the MDs were stated, for example during diagnostic laparoscopy in symptomatic patients suspicious for IH or during laparoscopic cholecystectomy. Technically well-executed closure of Petersen's space (PS) with two rows of staples had a greater chance of still being closed upon re-inspection compared to closure with one row (odds ratio = 8.1; 95% confidence interval [1.2-53.2], p = 0.029). Optimal closure of the MD at the jejuno-jejunostomy (JJ-space, JJS) resulted in more closed JJSs upon re-inspection compared to sub-optimal closure (odds ratio = 3.6 [CI 95% 0.8-16.1], p = 0.099). Non-optimally closed MDs had higher reopening rates and, therefore, pose an additional risk for IH. Our classification provides a quality assessment of MD closure during RYGB and gives insight into how to optimize surgical technique.

Smoking Is Correlated to Internal Hernia After Gastric Bypass Surgery: a Post hoc Analysis of Data from a Randomized Clinical Trial.

PURPOSE: Internal herniation is a well-known complication of laparoscopic Roux-en-Y gastric bypass (L-RYGB). The aim of this study was to evaluate smoking as an independent risk factor for internal herniation after L-RYGB. MATERIALS AND METHODS: This study was performed as an exploratory post hoc analysis of data from a previous published randomized controlled trial (RCT) designed to compare closure and non-closure of mesenteric defects in patients undergoing L-RYGB. The primary outcome of this study was to assess the significance of smoking as a risk factor for internal herniation after L-RYGB. Secondary outcome was early postoperative complications defined as Clavien-Dindo grade ≥ 2. RESULTS: Four hundred one patients were available for post hoc analysis. The risk of internal herniation was significantly higher among patients who were smoking preoperatively (hazard ratio (HR) 2.4, 95% confidence interval (c.i.) 1.3 to 4.5; p = 0.005). This result persisted after adjusting for other patient characteristics (HR 2.2, 1.2 to 4.2; p = 0.016). 6.0% of the patients had postoperative complications within the first 30 days. 4.9% of these patients were smoking and 6.3% were not smoking, p = 0.657. 11.0% of the patients underwent surgery due to internal herniation by 5 years after the primary procedure. CONCLUSION: Smoking is a significant risk factor for internal herniation but did not increase risk for 30 days postoperative complications.

Post-appendicectomy small bowel obstruction due to internal hernia involving Meckel's diverticulum.

Meckel's diverticulum is the most common congenital abnormality of the small bowel, present in about 2% of the population. A man in his 20s underwent a laparoscopic appendicectomy for acute appendicitis and recovered uneventfully. He presented to the emergency department 1 month later with features of acute small bowel obstruction. Emergency diagnostic laparoscopy revealed a band adhesion between the apex of a Meckel's diverticulum to the appendicectomy stump. Internal herniation of ileum under this band adhesion resulted in small bowel obstruction and ischaemic necrosis of the Meckel's diverticulum. The band adhesion was divided, and the Meckel's diverticulum was resected at the base with a linear cutting stapler. This complication has not been reported previously. A Meckel's diverticulum is an important differential diagnosis of acute appendicitis and should routinely be searched for among other pathologies. It can rarely cause a postoperative complication of internal hernia.

Predictors of Length of Hospital Stay After Reduction of Internal Hernia in Patients With a History of Roux-en-Y Gastric Bypass.

BACKGROUND: Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited. METHODS: This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5 year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS. RESULTS: We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1 years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43 months. Petersen's defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen's and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2 days. On the multivariate analysis, male sex (P = .019), conversion to exploratory laparotomy (P = .005), and resection of small bowel (P < .001) were independent risk factors for increased LOS. CONCLUSION: The most common location of IH after RYGB is Petersen's defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel.

Internal hernia through the foramen of Winslow: a rare cause of intestinal obstruction with imminent ischaemia of the caecum.

An internal hernia through the foramen of Winslow represents a rare surgical pathology. This report describes a case with incipient caecal ischaemia and discusses current diagnostic and therapeutic approaches. A patient in his early 60s presented at the emergency department with abdominal pain and last bowel movement three days prior. A CT scan of the abdomen suggested an internal hernia into the lesser sac. Intraoperatively, the suspected diagnosis could be confirmed laparoscopically with a twisted mobile caecum herniating through the foramen of Winslow. Due to a suspected ischaemia and laparoscopic frustrated reduction, a right open hemicolectomy was performed. The hernia gap was closed. The postoperative course was uneventful. Despite the rarity of internal hernias in patients without prior abdominal surgery, surgeons should be aware of this entity. The diagnosis can be difficult and sometimes only established intraoperatively. Open surgery is usually required. If the gap is clearly identified, the recommendations tend towards its closure.

Untangling diagnostic confusion in internal abdominal hernias.

BACKGROUND: Internal hernias involve the herniation of intestines through mesenteric or peritoneal defects in the gastrointestinal system. Etiologically, they are generally classified as congenital or acquired. Internal hernias often present with non-specific symptoms. Despite the increased use of computed tomography (CT), discrepancies between imaging findings and diagnostic accuracy continue to pose challenges for clinicians. This study aims to compare the outcomes of patients presenting to the emergency department with abdominal pain and receiving a preliminary internal hernia diagnosis through CT, followed by laparotomy. METHODS: Our research is a retrospective, observational, and descriptive study. It includes patients presenting to the emergency department with abdominal pain, who were provisionally diagnosed with internal hernia based on CT. Patient data recorded age, gen-der, CT-identified internal hernia type, surgery, diagnoses, hospitalization status, duration of hospital stay, bowel resection, mortality, and blood parameters. The Welch classification was used to categorize internal hernia types, with eight types examined. RESULTS: Among 112 patients with a preliminary internal hernia diagnosis based on abdominal CT, the median age was 52 years. Of these, 46 were female and 66 were male. Among all patients, 87 were admitted to the hospital for observation and surgery, while 25 were discharged after emergency department. Paraduodenal hernias were the most common provisional diagnosis (48 cases). Among these patients, 45 were discharged after symptom relief and were advised for elective re-evaluation. The exact diagnosis for these pa-tients remains unknown. Post-surgery, the diagnosis of internal hernia was confirmed in 32 cases. Among them, 15 were female and 17 were male, with a median age of 52. The median hospital stay for patients diagnosed with internal hernia was 5 days. Although acquired hernias exhibited higher resection and mortality rates, no statistically significant difference was found. Thirty-five cases received dif-ferent diagnoses: 19 had brid ileus, five had volvulus, six had acute appendicitis, one had duodenal perforation, three had gynecological malignancies, and one had renal malignancy. CONCLUSION: Although internal hernias are rare, early diagnosis and treatment are very important due to the high risk of death. The study findings indicate that increased CT utilization leads to earlier diagnosis and treatment, resulting in improved prognosis for patients. This study holds one of the largest case series in the literature. It provides a novel perspective by evaluating radiologically-diagnosed cases, confirming diagnoses post-surgery, and comparing conditions that mimic internal hernias, thereby making a valuable contribution to the literature.