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Fig. 2 Pericaecal hernias
Ileocolic hernia
Paracaecal
hernia
Retrocaecal
hernia
G. D. Tebala et al.
Ileocaecal hernia
Post-traumatic hernias of the diaphragm can happen at any time after a blunt
(5%) or penetrating (19%) trauma of the torso. A diaphragmatic defect can be diagnosed at the time of the trauma laparotomy (about 50% of cases) or subsequently,
even as late as several years after the trauma, usually after a clinical presentation
with thoracic pain, respiratory failure, dysphagia due to stomach inlet or outlet
obstruction or small and/or large bowel obstruction. Sometimes they are discovered
incidentally during investigations done for other reasons in asymptomatic patients.
Most diaphragmatic hernias occur through the left hemidiaphragm (about 90%),
due to the protective presence of the liver on the right, but right diaphragmatic hernias may follow liver resectional surgery if a small diaphragmatic lesion goes undiagnosed and worsens progressively over a number of years. Post- oesophagectomy
diaphragmatic hernias occur in just over 2% of cases and appear to be more common after laparoscopic than open oesophagectomy [8, 9]. However, higher rates
have been reported in more recent studies [10], which beg the question as to whether
the complication is under-reported, or whether the increased incidence can be attributed to the larger proportion of cases done via the minimally invasive approach.
Complicated hiatus hernia treatment is the subject of another chapter of this book.
2.2 Clinical Findings
There is a variable spectrum of presentation ranging from hours to years postoperatively, and symptoms may be acute or chronic. Sixty-nine percent of patients
who developed internal hernia following colorectal resection presented within
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Fig. 3 Intersigmoid
hernias
191
Intersigmoid hernia
10days of the initial operation [4], whereas for bariatric surgery patients, the highest incidence happens at around 1–2years post-surgery, which corresponds to the
greatest period of weight loss [11]. While the incidence of acute presentations is
low, the true incidence of post-operative internal hernias is likely to be far greater
than that quoted in literature. Small bowel herniating behind the neo-descending
colon has been identied radiologically in 21% of asymptomatic patients following
laparoscopic anterior resection [12]. Additionally, in a non-acute context, internal
hernias have been found in patients with unexplained intermittent abdominal pain
following bariatric procedures [3]. Therefore, a high index of suspicion must be
maintained.
Clinically, the range of symptoms from internal hernias ranges from no symptoms to acute abdominal pain, often vague epigastric pain or intermittent colicky
periumbilical pain. This pain is often associated with non-specic symptoms such
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Fig. 4 Petersen’s hernia
and transmesenteric hernia
G. D. Tebala et al.
Petersen’s hernia
Transmesenteric
hernia
as nausea, vomiting or abdominal distention, which can complicate diagnosis.
Diaphragmatic hernias may also present with acute respiratory distress. Symptom
severity relates to the duration and reducibility of the hernia and the presence or
absence of incarceration and strangulation. Examination ndings may demonstrate
a palpable intra-abdominal mass of herniated loops with localised tenderness. It is
important to highlight that the clinical presentation of an internal hernia is often that
of an acute bowel obstruction, and symptoms and initial assessment overlap those
of bowel obstruction.
Post-traumatic and post-surgical diaphragmatic hernias can present with symptoms of chest pain, gastric inlet or outlet obstruction (nausea, vomiting, dysphagia)
and progressive or acute respiratory failure due to compression of the lung or the
inferior vena cava.
Every patient presenting with acute bowel obstruction or acute abdomen must be
thoroughly assessed for comorbidities and acute complications such as bowel ischaemia. It is crucial to collect a thorough clinical history, in particular regarding
recurrent and vague symptoms of abdominal pain, with or without vomiting and
nausea, weight loss, reduction of appetite and any prior history of abdominal operations or traumas. A complete set of blood tests must be sent including haemoglobin,
inammatory markers, renal and liver function tests, coagulation, lactate and blood
gases, bearing in mind that in most non-hyperacute cases, blood tests may be normal.
Due to the generally vague and non-specic nature of typical clinical ndings,
diagnosis is often delayed, and therefore the risk of complications is high, which
highlights the importance of prompt and thorough investigation.
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2.3 Investigations
Although the nal diagnosis of internal hernia can be done only with direct exploration, contrast-enhanced CT scan is the rst-line investigation and can demonstrate
features of small or large bowel obstruction, with or without a clear transition point
(Figs.5 and 6). However, CT scan can be falsely negative in up to 50% of cases [13].
The usual radiological appearance is of crowded and often encapsulated dilated
small bowel loops. Other commonly observed radiological signs include the ‘swirl
sign’ described as the swirling appearance of mesenteric fat and vessels found in
95% [14], superior mesenteric vein ‘beaking’ in 81% (where the vein appears to
taper off), and the ‘mushroom’ shape of herniated bowel which is present in 62% of
patients with internal hernia [15].
In hernias of the foramen of Winslow, a loop of bowel can be seen in the lesser
sac, posteriorly and cephalically to the stomach and anteriorly and cephalically to
the pancreas. The transition point is usually posterior to the hepatic pedicle (Fig.5).
It is not unusual that the herniated loop pushes posteriorly on the common bile duct,
causing mild dilatation of the intra-hepatic ducts.
In diaphragmatic hernias, the typical CT nding is of bowel (or any other
abdominal organ) transposed into the chest, usually dilated and with air-uid level
(Fig.6).
Following bariatric procedures, bowel loops behind the superior mesenteric
artery were only observed in 29% but had a very high positive predictive value [16].
Fig. 5 Hernia of the foramen of Winslow, CT scan. Whole ascending colon with terminal ileum
and proximal transverse colon migrated into the lesser sac through the foramen of Winslow
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Fig. 6 Post-traumatic diaphragmatic hernia, CT scan. Dilated bowel transposed into the left chest
cavity with air-uid level
G. D. Tebala et al.
However, it must be observed that positive CT ndings can be seen only in 74% of
patients with Petersen’s hernia [17] which tends to occur post Roux-en-Y gastric
bypass, and diagnostic laparoscopy is much more reliable than CT scan in evaluating abdominal pain for possible internal hernia in these patients [13].
After colonic resections, U- or C-shaped small bowel loops can be apparent on
CT postero-laterally to transposed transverse colon or left neo-descending colon
and anterior to the retroperitoneum [6, 18, 19].
CT signs of bowel ischaemia include reduced enhancement of the bowel wall,
thickening of the bowel wall, small bowel dilatation, the presence of peritoneal
uid, congestion of small veins, ascites, pneumatosis of the bowel wall and portomesenteric venous gas [20, 21]. Although plain chest X-rays can show large diaphragmatic and hiatal hernias, the reliability of plain abdominal lms is generally
quite low, and we do not suggest performing any plain lm before or after the CT
scan. Similarly, the diagnostic value of barium or water-soluble contrast studies is
minimal, unless in the context of an attempted conservative management with
water-soluble oral contrast where the progression of the contrast medium within the
gastrointestinal tract may be a useful diagnostic aid as well as a therapeutic one. In
experienced hands, an abdominal ultrasound scan can show features of bowel
obstruction and even rule out intestinal ischaemia, but nowadays a quick and complete contrast-enhanced abdominopelvic CT scan remains the investigation
of choice.
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2.4 Prevention
Generally, the traditional rule has always been to close every mesenteric defect that
can potentially give rise to an internal hernia. This is mandatory in small bowel
resections and in small segmental resections of the large bowel where the mesenteric defect is small, and therefore any internal hernia would have a high likelihood
of strangulation. There has been much debate on the necessity of closing large
defects, such as the posterior space behind a gastrojejunostomy or the mesocolic
defect after a right or left colectomy, in particular after the introduction of laparoscopic surgery where closure of the peritoneal defects may not be easy.
There are clear recommendations for reduction of internal hernias following
laparoscopic upper gastrointestinal procedures and bariatric surgery. Closure of the
mesenteric defects is widely recommended following Roux-en-Y gastric bypass.
Closure of one defect has been reported to reduce the incidence from 3.5% to 1.7%
[22], and closure of both defects may further halve the incidence in comparison to
only closing one defect [23]. A recent meta-analysis of more than 10,000 pooled
patients who underwent Roux-en-Y gastric bypass revealed that closing the defects
reduces the risk of internal hernias, in both observational and randomised studies
(odds ratio 0.28 and 0.29, respectively) [24]. Numerous methods of closure have
been trialled, including sutures, staples and glue with no conclusive recommendation. Closure of mesenteric defects is commonly performed with continuous nonabsorbable sutures with the rst stitch placed at the transition between small bowel
serosa and mesentery [11]. Care should be taken not to cause kinking of the jejunojejunal anastomosis [25]. An antecolic, antegastric approach for Roux-en-Y gastric
bypass has been suggested to prevent formation of a potential space in the transverse mesocolon and has been reported to have a fourfold reduced risk in comparison to a retrocolic approach [26].
Hiatoplasty does not appear to prevent trans-hiatal post-oesophagectomy hernias
[9], but many surgeons would tend to reduce the hiatus anyway and may also suture
the transposed gastric tubule to the crura before or after the oesophageal anastomosis.
There is no clear evidence whether the large mesenteric defects created by
colorectal surgery should be closed routinely [27]. A recent cohort study on 198
patients showed that 21% of patients who underwent an anterior resection develop
an asymptomatic internal hernia, but only a small percentage (0.5%) present with
small bowel obstruction [12]. That study proposes that a routine closure of the
defect should be considered, but they did not explore the risks related to this
manoeuvre, such as closing or kinking the ureter with a stich or injuring the left
colic pedicle. Similarly, there is no consensus as to whether the splenic exure
should be fully mobilised or not. Full mobilisation creates a larger defect for potential herniation, whereas incomplete mobilisation may increase the risk of incarceration should herniation occur [9]. Some studies suggest repositioning the small
bowel to the contralateral side from the resection to prevent immediate postoperative internal herniation [9], but we suggest that, after the anastomosis, the
surgeon routinely checks if any small bowel loop has remained trapped behind the
transposed colon. The large mesocolic defect in distal colectomies can be safely
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closed with glue [28], but sutures increase the risk of vascular injuries and subsequent distal ischaemia [27]. However, routine closure of the defect may be justied
by the high mortality associated with postoperative internal hernia.
G. D. Tebala et al.
2.5 Treatment
The treatment of these patients follows the evidence and guidelines for small bowel
obstruction [29], with some adaptation. In stable patients with no signs of peritonitis, strangulation or bowel ischaemia, initial non-operative management can potentially be attempted. However, having a precise diagnosis is mandatory as an
excessive delay may lead to extremely severe complications such as bowel ischaemia. Delayed surgery may increase mortality and morbidity [30], but emergency
laparotomies also carry a high burden of risk, and therefore an initial non-operative
treatment plan is justied. Early laparoscopic exploration may be a good option in
some selected patients where the CT scan cannot denitively rule out ischaemia of
the bowel. However, some internal hernias should be immediately referred for surgery as they are particularly high risk for ischaemia and recurrence.
Non-operative management should not extend beyond 3days [30] and would
entail fasting and gastric decompression through a nasogastric tube. The administration of water-soluble contrast may facilitate the early resolution of obstruction and
also has diagnostic value as it may demonstrate a complete obstruction which would
prompt an early operation. The patient should concurrently be maintained on intravenous uids or total parenteral nutrition. However, it is worth emphasising that
non-operative management is a risky strategy in patients with suspected internal
hernia, and its choice must be based on clear criteria and convincing the absence of
ischaemia or perforation on the CT scan.
If conservative management fails or if there are signs of ischaemia at CT or at
blood tests (lactate), surgical exploration is mandatory. A laparoscopic exploration
has the dual purpose of both diagnosis and treatment. The vast majority of internal
hernias after laparoscopic operation can be treated laparoscopically, in particular
those that occur after gastric bypass [31]. This is the case, for instance, with a
Petersen’s hernia or obstruction of the small bowel loops entrapped below the transposed transverse colon after distal colectomy. Many cases have been reported in the
literature, but no large series. A recent comparatively small cohort study from Japan
[32] showed that laparoscopic repair of Petersen’s hernia has some advantages with
respect to open surgery in terms of quicker recovery but demonstrated no difference
in operative time, mortality and morbidity.
However, the laparoscopic approach is not easy and is further complicated by
two factors due to the underlying pathology; the distension of the obstructed bowel
may reduce the operative eld in the abdomen, and oedema of the bowel loops may
hamper reduction of the hernia sac. Furthermore, the laparoscopic approach needs
a skilled surgeon who has experience in surgery for obstructed bowel, as the risk of
bowel injury is extraordinarily high in those conditions.
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Clearly the surgical technique changes according to the site of the hernia. We
suggest putting the patient in a Lloyd-Davies position, with legs on stirrups so that
the surgeon can stand between the legs of the patient, if needed. This is particularly
important in diaphragmatic hernias as it gives good laparoscopic access to the upper
abdomen.
The operation should start with an exploration of the abdomen through a port
located as centrally as possible. For the rst trocar, the use of the blunt ‘Hasson’
technique is highly recommended, in particular for patients who have had multiple
abdominal operations and certainly in those with a massively distended abdomen.
Clearly, the classical laparoscopic rules still apply on where to obtain the initial
access. The umbilical position provides good access to all abdominal quadrants but
may be complicated by a midline scar, and the right upper quadrant (Palmer’s point)
should be considered for these patients.
The position of the other ports depends on the planned operation while also taking into account the correct triangulation of the ports. Three ports including the one
for the laparoscope guarantee good access and good manoeuvrability within the
abdomen but may not be enough. Overtly distended bowel or diffuse faecal or
enteric contamination as well as complications or other difculties in carrying out a
laparoscopic operation may require a prompt conversion to open surgery. In the case
of an unstable patient or in the absence of a suitably skilled laparoscopic surgeon, it
is still perfectly acceptable to approach these conditions with a routine midline
laparotomy.
The initial inspection of the abdominal cavity is aimed at ruling out ischaemia or
perforation of the bowel. In case of perforation, free gas would escape as soon as the
rst trocar is inserted. The surgeon should look for free intestinal content and/or pus
in the abdomen, as well as any localised collections of pus or bile, before following
the bowel to nd the transition point of the obstruction. Where there is a strangulated closed loop, the bowel may be ischaemic or frankly necrotic. In hernias of the
lesser sac, it is possible to see the herniated loop of bowel bulging through the
hepato-gastric ligament (Fig.7).
Mobilisation of the herniated bowel should happen with delicate traction on the
bowel or omentum but avoiding traction on the mesentery wherever possible (Figs.8
and 9). If this is not feasible, it may be necessary to incise the neck of the hernia. The
Fig. 7 Hernia of the
foramen of Winslow, same
clinical case as Fig.5. The
dilated caecum can be seen
through the hepatogastric
ligament
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Fig. 8 Hernia of the
foramen of Winslow, same
clinical case as Fig.5.
Afferent and efferent loops
passing below the hepatic
pedicle
Fig. 9 Post-traumatic
diaphragmatic hernia, same
clinical case as Fig.6,
intraoperative view. The
herniated bowel is
cautiously pulled back into
the abdomen
G. D. Tebala et al.
surgeon must fully consider the anatomy of the internal hernia when deciding where
to make the incision rather than making it randomly. As previously mentioned, very
often at least one of the sides of the neck of the hernia contains a major vessel (see
Table 1), and therefore the incision must be made as far as possible from it. After
mobilising the hernia, the viability of the bowel must be fully established with immediate inspection of the serosal surface and review again after re-warming (either
using wet hot swabs or simply immersion in warm water). If the bowel is frankly
necrotic or its appearance does not improve after several minutes of re- warming, then
resection and anastomosis are indicated. The viability of the bowel can also be established with the use of IndoCyanine Green (ICG) uorescence using a near-infrared
light [33]. The aim of the next steps of the operation is to reduce the risk of recurrent
internal hernia. If possible, the defect should be closed with suture, glue or mesh.
Left and right paraduodenal, paracaecal and intersigmoid recesses and mesenteric or mesocolic defects should either be closed with glue or with sutures involving only the peritoneal layers, to avoid damaging the underlying vascular structures.
Defects of the transverse mesocolon at the point of passage of a jejunal limb heading to or from a supramesocolic anastomosis must be reduced by suturing the edges
of the defect to the bowel going through it and its mesentery directly or with the
interposition of greater omentum. The retrocolic space created after transposition of
the transverse colon towards the pelvis is usually a wide space, and obstructions of
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a herniated loop of small bowel happen only when the latter is compressed by the
large bowel and xed by adhesions. After mobilising the herniated bowel, it may be
advisable to glue or suture the transverse mesocolon to the fascia of Gerota from the
duodenojejunal angle to the pelvis. However, this suture may reduce the space
behind the colon without closing it completely, thus predisposing to the risk of a
recurrence of the hernia through a much tighter space. When xing these hernias,
consider that in these cases, the herniation of the small bowel does not usually happen spontaneously but rather during the original colectomy and that the transposed
transverse mesocolon tends to attach spontaneously to the fascia of Gerota, and
therefore the simple extraction of the small bowel from behind the transverse colon
without any other manoeuvre may well sufce, provided that the bowel is still viable.
In case of hernia of the lesser sac, the foramen of Winslow must be closed, possibly with a running suture, making sure that only the peritoneum is taken with the
stitches and that the elements of the hepatic pedicle (mostly, the common bile duct)
are not kinked or sutured.
Retroanastomotic hernias such as Petersen’s hernias also require the closure of
the defect. This can be accomplished with a running suture with a slowly absorbable
material or with glue. Another option would be to open up the defect completely in
order to allow easy passage of small bowel in and out the defect, for example, with
right paraduodenal hernias. To reduce a right paraduodenal hernia and prevent
recurrence, it may be necessary to completely mobilise the right colon with a
Cattell’s manoeuvre, either laparoscopically or via laparotomy. The whole right
colon and proximal transverse must be repositioned into the left abdomen so to open
the right paraduodenal recess wide and prevent further herniation. This is in contrast
to the repair of left paraduodenal hernias where the hernia sac is opened along the
base of the descending mesocolon.
Acute post-traumatic diaphragmatic hernias are often treated with open surgery
due to as yet unresolved concerns on the use of laparoscopy in the acute trauma setting, unless it is an isolated diaphragmatic injury, bearing in mind that acute laparoscopy may miss associated injuries in up to 40% of cases. However, acute cases
are often easier than chronic ones as the defect is well dened, and there has not yet
been time for adhesions to form [34]. More commonly, diaphragmatic hernias do
not present until months or years after the trauma and are usually approached laparoscopically (Figs.9, 10, and 11).
The repair of a hiatus or diaphragmatic hernia is better standardised than intraperitoneal hernias, usually because CT scan is more reliable for diagnosis. However,
it is important to have a degree of exibility in the position of the trocars. A posttraumatic diaphragmatic hernia can be approached with only three trocars. We tend
to put the rst port on the parasternal line, about 5–10cm above the umbilicus, in
line with the stomach and the oesophagus, although a more central position is an
acceptable alternative position. The two operating ports are usually inserted about
10cm to the left and right of the main port and slightly cephalad, below the costal
margin. An additional port for the liver retractor can be inserted in the epigastrium
or in the right ank, while a port to help with the traction on the herniated viscera
may be useful if inserted on the patient’s left side.
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