Internal Herniashernias Whatwhat Youyou Mustmust Knowknow

INTERNALINTERNAL HERNIASHERNIAS WHATWHAT YOUYOU MUSTMUST KNOWKNOW

Richard M. Gore, MD NorthShore University Health System University of Chicago Evanston, IL SCBT/MR 2010 San Diego, California March 8, 2010 15:40-15:50 OBJECTIVESOBJECTIVES

•• EmphasizeEmphasize thethe clinicalclinical importanceimportance andand prevelanceprevelance ofof internalinternal herniashernias •• ReviewReview thethe typestypes ofof internalinternal herniashernias •• DescribeDescribe thethe clinicalclinical andand imagingimaging featuresfeatures ofof thesethese herniashernias INTERNALINTERNAL HERNIASHERNIAS

•• ProtrusionProtrusion ofof thethe gutgut throughthrough thethe peritoneum,peritoneum, mesentery,mesentery, oror omentumomentum intointo aa compartmentcompartment inin thethe abdominalabdominal cavitycavity •• TheThe herniahernia orificeorifice isis usuallyusually aa preexistingpreexisting foramen,foramen, recess,recess, andand fossafossa butbut cancan bebe causedcaused byby surgery,surgery, ischemia,ischemia, andand traumatrauma INTERNALINTERNAL HERNIASHERNIAS

•• CongenitalCongenital defectsdefects areare anomaliesanomalies ofof intestinalintestinal rotationrotation andand mesentericmesenteric attachmentsattachments •• AutopsyAutopsy incidenceincidence 0.20.2 -- 0.9%0.9% WHYWHY INTERNALINTERNAL HERNIASHERNIAS AREARE IMPORTANTIMPORTANT

•• IHIH shouldshould bebe aa majormajor defaultdefault diagnosisdiagnosis inin patientspatients withwith SBO,SBO, especiallyespecially withwith closedclosed looploop oror strangulatingstrangulating featuresfeatures •• ContributorContributor toto tsunamitsunami ofof requestsrequests forfor outpatientoutpatient abdominalabdominal CTCT scansscans forfor abdominalabdominal discomfortdiscomfort andand painpain •• SourceSource ofof chronicchronic andand intermittentintermittent bowelbowel obstrutionobstrution CAUSESCAUSES OFOF SMALLSMALL BOWELBOWEL OBSTRUCTIONOBSTRUCTION

•• ADHESIONSADHESIONS 49%49% •• HERNIASHERNIAS 30%30% •• NEOPLASMSNEOPLASMS 15%15% •• OTHEROTHER 6%6% HERNIASHERNIAS ASAS CAUSECAUSE OFOF BOWELBOWEL OBSTRUCTIONOBSTRUCTION

•• INTERNALINTERNAL HERNIASHERNIAS 33%33% •• EXTERNALEXTERNAL HERNIASHERNIAS 66%66% HERNIASHERNIAS ASAS CAUSECAUSE OFOF STANGULATIONSTANGULATION

•• INTERNALINTERNAL HERNIASHERNIAS 40%40% •• EXTERNALEXTERNAL HERNIASHERNIAS 60%60% INTERNALINTERNAL HERNIASHERNIAS

•• PreoperativePreoperative diagnosisdiagnosis cancan bebe difficult:difficult: S+SS+S rangerange fromfrom highhigh gradegrade bowelbowel obstructionobstruction toto mildmild digestivedigestive complaintscomplaints •• IfIf reduciblereducible theythey areare oftenoften silentsilent •• IHIH areare thethe mostmost commoncommon causecause ofof strangstrang-- ulatingulating obstructionobstruction INTERNALINTERNAL HERNIASHERNIAS

•• DuringDuring thethe pastpast decadedecade thethe incidenceincidence ofof IHIH hashas increasedincreased duedue toto moremore frequentfrequent bariatricbariatric surgerysurgery andand liverliver transplantationtransplantation •• RYGBRYGB isis associatedassociated withwith anan increasedincreased incidenceincidence ofof transmesenteric,transmesenteric, transmesocolictransmesocolic andand retroanastomoticretroanastomotic internalinternal herniashernias TYPESTYPES OFOF INTERNALINTERNAL HERNIASHERNIAS

• Broad ligament • Fossa of Douglas • Perirectal fossa

Radiographics 25: 997-1015, 2005 TYPESTYPES OFOF INTERNALINTERNAL HERNIASHERNIAS

• Left paraduodenal • Right paraduodenal • Pericecal • Foramen of Winslow • Transomental • Intersigmoid • Transmesenteric • Retroanastomotic

Radiographics 25: 997-1015, 2005 INTERNALINTERNAL HERNIASHERNIAS

•• ParaduodenalParaduodenal 53%53% •• PericecalPericecal 13%13% •• ForamenForamen ofof WinslowWinslow 8%8% •• TransmesentericTransmesenteric 8%8% •• IntersigmoidIntersigmoid 6%6% •• SupravesicalSupravesical--pelvicpelvic 6%6% •• TransomentalTransomental 11--4%4% PARADUODENALPARADUODENAL HERNIASHERNIAS

•• ParaduodenalParaduodenal fossaefossae originateoriginate asas congenitalcongenital peritonealperitoneal anomaliesanomalies duedue toto failurefailure ofof mesentericmesenteric fusionfusion withwith thethe parietalparietal peritoneumperitoneum andand anan associatedassociated abnormalabnormal rotationrotation asas thethe SBSB isis imprisonedimprisoned beneathbeneath thethe developingdeveloping coloncolon INTERNALINTERNAL HERNIAS:HERNIAS: AIDSAIDS ININ PREOPERATIVEPREOPERATIVE DIAGNOSISDIAGNOSIS

• Engorged, stretched, and displaced mesenteric vascular pedicle and convergence of vessels at the hernia orifice • Saclike mass or cluster of dilated SB loops at an abnormal anatomic location in the setting of SBO • Knowledge of the normal anatomy of the peritoneal cavity and characteristic anatomic location PARADUODENALPARADUODENAL FOSSAEFOSSAE

• Superior duodenal fossa • Inferior duodenal fossa (Treitz) • Paraduodenal fossa (Landzert) • Intermesocolic (Broesike) • Mesentericoparietal (Waldeyer) PARADUODENALPARADUODENAL FOSSAEFOSSAE

•• ParaduodenalParaduodenal fossafossa (Landzert)(Landzert) foundfound inin 2%2% ofof autopsiesautopsies-- inducesinduces leftleft PDHPDH •• MesentericoparietalMesentericoparietal (Waldeyer)(Waldeyer) foundfound inin 1%1% ofautopsiesofautopsies-- inducesinduces rightright PDHPDH PERICECALPERICECAL HERNIAHERNIA

•• 44 pericecalpericecal recessesrecesses cancan bebe involvedinvolved withwith hernias:hernias: retrocecal,retrocecal, paracolic,paracolic, superiorsuperior ileocecal,ileocecal, inferiorinferior ileocecalileocecal •• 13%13% ofof allall internalinternal herniashernias AJR 186: 703-717, 2006 PERICECALPERICECAL HERNIAHERNIA

• Ileal loops occupy the right paracolic gutter • Clustering of fluid filled SB lateral to the cecum and posterior to the ascending colon • Tethering at the aperture of the peritoneal recess and dilation of SB with a transition zone • Patients may present with acute abdomen • Chronic incarceration may be difficult to differentiate from IBD, appendiceal disorders and other causes of SBO SIGMOIDSIGMOID MESOCOLONMESOCOLON HERNIAHERNIA

• The intersigmoid fossa lies behind the apex of the V- shaped parietal attachment of the sigmoid mesocolon • This pocket is found in 65% of autopsies • Accounts of 6% of all internal hernias • Three types: intersigmoid; transmeso-sigmoid; intermesosigmoid AJR 186: 703-717, 2006 SIGMOIDSIGMOID MESOCOLONMESOCOLON

• CONTAINS THE SIGMOID AND HEMORRHOIDAL VESSELS OF THE IMA AND IMV • CONTINUOUS WITH THE BARE AREA OF COLON AND RECTUM, AND BROAD LIGAMENT • CONFINES THE SPREAD OF DIVERTICULITIS • PATHWAY OF DISEASE SPREAD BETWEEN SIGMOID AND OVARY TRANSOMENTALTRANSOMENTAL HERNIAHERNIA

•• AccountsAccounts forfor 1%1% -- 4%4% ofof allall internalinternal herniashernias •• TypeType II-- throughthrough thethe freefree edgeedge ofof thethe GOGO •• TypeType IIII-- throughthrough thethe GCLGCL intointo thethe lesserlesser sacsac TRANSOMENTALTRANSOMENTAL HERNIAHERNIA

•• TypeType II-- mostmost common,common, throughthrough aa slitslit likelike openingopening (2(2--1010 cmcm inin diameter)diameter) atat thethe peripheryperiphery ofof thethe freefree edgeedge ofof thethe GOGO •• SB,SB, cecum,cecum, andand sigmoidsigmoid maymay bebe involvedinvolved •• ClinicalClinical andand radiologicradiologic featuresfeatures areare almostalmost identicalidentical toto transmesenterictransmesenteric herniashernias TRANSMESENTERICTRANSMESENTERIC HERNIAHERNIA

•• InIn adultsadults mostmost mesentericmesenteric defectsdefects areare thethe resultresult ofof surgery,surgery, trauma,trauma, oror inflammationinflammation •• SBOSBO developsdevelops inin mostmost casescases duedue toto thethe absenceabsence ofof aa limitinglimiting herniahernia sacsac •• CannotCannot differentiatedifferentiate closedclosed looploop SBOSBO causedcaused byby transmesenterictransmesenteric herniahernia vsvs prolapseprolapse ofof intestineintestine underunder adhesiveadhesive bandsbands FORAMENFORAMEN OFOF WINSLOWWINSLOW HERNIAHERNIA

• 8% of all internal hernias • SB most frequently involved (60%-70%) • TI, cecum, ascending colon (25-30%) • GB, transverse colon, and omental hernias are rare • Risk factors: enlarged foramen, excessively mobile gut due to a long mesentery, persistence of the ascending mesocolon, ascending mesocolon that is not fused to the parietal peritoneum FORAMENFORAMEN OFOF WINSLOWWINSLOW HERNIA:HERNIA: CTCT FINDINGSFINDINGS

•• MesenteryMesentery interposedinterposed betweenbetween IVCIVC andand mainmain portalportal veinvein •• AirAir--filledfilled collectioncollection inin thethe lessless sacsac withwith beakbeak directeddirected towardstowards thethe epiploicepiploic foramenforamen •• AbsenceAbsence ofof thethe ascendingascending coloncolon inin thethe rightright paracolicparacolic guttergutter •• ≥≥ 22 bowelbowel loopsloops inin thethe highhigh subhepaticsubhepatic spacesspaces SUPRAVESICALSUPRAVESICAL HERNIAHERNIA

•• SupravesicalSupravesical fossafossa isis locatedlocated betweenbetween thethe remnantsremnants ofof thethe medialmedial andand leftleft--rightright umbilicalumbilical ligamentsligaments •• SacSac maymay remainremain aboveabove thethe pelvispelvis formingforming anan externalexternal supravesicalsupravesical herniahernia oror passpass caudallycaudally andand formform anan internalinternal supravesicalsupravesical herniahernia BROADBROAD LIGAMENTLIGAMENT HERNIAHERNIA

•• 4%4% -- 5%5% ofof allall internalinternal herniashernias •• SBSB isis thethe herniatedherniated gutgut inin >> 90%90% •• >> 85%85% inin parousparous womenwomen •• CongenitalCongenital andand aquiredaquired •• AcquiredAcquired defectsdefects duedue toto surgicalsurgical trauma,trauma, pregnancypregnancy andand birthbirth trauma,trauma, perforationsperforations followingfollowing vaginalvaginal manipulation,manipulation, PIDPID BROADBROAD LIGAMENTLIGAMENT HERNIAHERNIA CLASSIFICATIONCLASSIFICATION

•• TypeType 1=1= defectdefect caudalcaudal toto roundround ligamentligament •• TypeType 22 == defectdefect aboveabove roundround ligamentligament •• TypeType 3=3= defectdefect betweenbetween thethe roundround andand broadbroad ligamentligament throughthrough thethe mesoligamentummesoligamentum teresteres BROADBROAD LIGAMENTLIGAMENT HERNIAHERNIA CTCT FINDINGSFINDINGS

•• ClusterCluster ofof dilateddilated SBSB withwith AA--FF levelslevels inin thethe pelvicpelvic cavitycavity •• DistendedDistended bowelbowel loopsloops compresscompress thethe rectosigmoidrectosigmoid dorsolaterallydorsolaterally andand thethe uterusuterus ventrallyventrally TRANSMESENTERICTRANSMESENTERIC OROR RETROANASTOMOTICRETROANASTOMOTIC INTERNALINTERNAL HERNIASHERNIAS FOLLOWINGFOLLOWING LIVERLIVER TRANSLANTATIONTRANSLANTATION

•• SBOSBO 100%100% •• MedialMedial duodenojejunalduodenojejunal junctionjunction 100%100% •• CentralCentral displacementdisplacement ofof coloncolon 100%100% •• EngorgedEngorged mesentericmesenteric vesselsvessels 100%100% •• CrowdingCrowding mesentericmesenteric vesselsvessels 100%100% •• ClusterCluster ofof SBSB loopsloops 88%88%

Blacher Radiology 218:384-388, 2001 TRANSMESENTERICTRANSMESENTERIC OROR RETROANASTOMOTICRETROANASTOMOTIC INTERNALINTERNAL HERNIASHERNIAS FOLLOWINGFOLLOWING LIVERLIVER TRANSLANTATIONTRANSLANTATION

•• CentralCentral displacementdisplacement ofof coloncolon 88%88% •• LackLack ofof overlyingoverlying omentalomental fatfat 88%88% •• DepressedDepressed duodenojejunumduodenojejunum 75%75% •• AscitesAscites 50%50% •• WhirlWhirl signsign 50%50% •• MuralMural SBSB thickeningthickening 50%50% •• SaclikeSaclike massmass 25%25%

Blacher Radiology 218:384-388, 2001 INTERNALINTERNAL HERNIASHERNIAS ASSOCIATEDASSOCIATED WITHWITH RYGBRYGB

•• TransmesocolicTransmesocolic •• SmallSmall bowelbowel mesenterymesentery •• PetersenPetersen typetype INTERNALINTERNAL HERNIASHERNIAS ASSOCIATEDASSOCIATED WITHWITH GASTRICGASTRIC BYPASS:BYPASS: CTCT FINDINGSFINDINGS

•• SwirledSwirled mesenterymesentery •• MushroomMushroom •• HurricaneHurricane eyeeye •• SBOSBO •• ClusteredClustered loopsloops •• SBSB behindbehind SMASMA •• RR sidedsided anastomosisanastomosis

Lockhart AJR 188: 745-750, 2007 THINKTHINK INTERNALINTERNAL HERNIAHERNIA

•• GASTRICGASTRIC BYPASSBYPASS PATIENTPATIENT

•• OBSTRUCTIONOBSTRUCTION WITHWITH NONO EXTERNALEXTERNAL HERNIAHERNIA OROR HISTORYHISTORY OFOF SURGERYSURGERY

•• CLOSEDCLOSED LOOPLOOP OROR STRANGULATIONSTRANGULATION BEBE VERYVERY SUSPICIOUSSUSPICIOUS

•• GutGut inin abnormalabnormal locationlocation •• SwirledSwirled mesenterymesentery •• SacSac--likelike collectioncollection ofof gutgut