AJR 2004; 183:397-404
© American Roentgen Ray Society
Internal Abdominal Herniations
Didier Mathieu1 and
Alain Luciani1 The GERMAD Group2
1 Services de Radiologie et d'Imagerie Médicale, Hôpital Henri
Mondor, 51 ave. du Maréchal de Lattre de Tassigny, Créteil
94010, France.
2 Groupe d'Etude Radiologique des Maladies de l'Appareil Digestif (GERMAD),
Paris, France
Received August 1, 2003;
accepted after revision January 12, 2004.
Address correspondence to D. Mathieu
(profdm{at}wanadoo.fr).
Introduction
An internal abdominal herniation is the protrusion of an abdominal organ
through a normal or abnormal mesenteric or peritoneal aperture
[1]. An internal abdominal
herniation differs from both an external abdominal herniation, in which the
protrusion occurs through an opening of the abdominal wall, and a
diaphragmatic herniation, which involves a weakness of the diaphragm. Internal
abdominal herniations can be either acquired through a trauma or surgical
procedure (iatrogenic internal abdominal herniations) or constitutional and
related to congenital peritoneal defects.
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, consisting of mild abdominal discomfort
alternating with episodes of intense periumbilical pain and nausea. CT is
believed to facilitate the diagnosis of internal abdominal herniations.
Specific signs of internal abdominal herniations on CT have been previously
reported
[2–4].
The use of CT could limit the rate of misdiagnosed internal abdominal
herniations because subtle transmesenteric internal abdominal herniations can
be difficult to diagnose on laparoscopy.
This pictorial essay focuses on constitutional internal abdominal
herniations (excluding iatrogenic and surgical internal herniations). We
review the main mechanisms of internal abdominal herniations and the main
radiologic findings on barium as well as CT studies.
Classification
The classifications of internal abdominal herniations devised by Ghahremani
[5] is now well accepted.
According to this classification system, internal abdominal herniations can be
separated in six main groups (Fig.
1): paraduodenal hernias (50–55% of internal abdominal
herniations), hernias through the foramen of Winslow (6–10%),
transmesenteric hernias (8–10%), pericecal hernias (10–15%),
intersigmoid hernias (4–8%), and paravesical hernias (< 4%).
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Fig. 1. —Illustration shows typical locations of different types of
internal abdominal herniations: 1 = paraduodenal, 2 = foramen of Winslow, 3 =
transmesenteric, 4 = pericecal, 5 = intersigmoid, 6 = paravesical (pelvic).
(Reprinted and modified with permission from
[5])
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Paraduodenal Hernias
Two types of paraduodenal hernias must be distinguished: left-sided
paraduodenal hernias, which account for 75% of all paraduodenal hernias, and
right-sided paraduodenal hernias, which account for the remaining 25%
[5].
Left-Sided Paraduodenal Hernias
In left-sided paraduodenal hernias (Figs.
2A,
2B, and
2C), small-bowel loops herniate
into an unusual fossa to the left of the duodenum referred to as the
paraduodenal fossa, or Landzert's fossa, that results from a congenital defect
in the descending mesocolon. This abnormal peritoneal pocket is bordered
anteriorly by a peritoneal fold overlying the inferior mesenteric vein and
ascending left colic artery [1,
5]. Proximal small-bowel loops,
duodenal segments, or even, in rare cases, distal ileal segments enter
posteriorly through the mesocolic defect, become entrapped in the Landzert's
fossa, and then extend further in the descending mesocolon.
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Fig. 2A. —Illustrations detail development of left-sided paraduodenal
hernia. (Reprinted with permission from
[1]) Small-bowel loops herniate
into descending mesocolon through paraduodenal fossa posterior to inferior
mesenteric vein and ascending left colic artery.
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Fig. 2C. —Illustrations detail development of left-sided paraduodenal
hernia. (Reprinted with permission from
[1]) Both inferior mesenteric
vein and left ascending colic artery always remain anterior to neck of
herniated sac in left-sided paraduodenal hernia.
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Radiographic findings of left-sided paraduodenal hernias are well
correlated to the anatomic topography. On barium examinations, the typical
finding is the presence of a mass of agglomerated small-bowel loops just
lateral to the fourth portion of the duodenum (Figs.
3A,
3B, and
3C) that is separated from the
remaining bowel loops and shows signs of obstruction (dilatation of
small-bowel loops or barium stasis) (Figs.
3A,
3B, and
3C).
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Fig. 3A. —41-year-old man who complained of midabdominal pain and
nausea. Conventional abdominal radiograph obtained with patient supine shows
mass in left upper quadrant (asterisk) compressing both stomach
(single arrowhead) and transverse colon (double
arrowhead).
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Fig. 3B. —41-year-old man who complained of midabdominal pain and
nausea. Radiograph from small-bowel series shows circumscribed ovoid mass of
multiple jejunal loops in left upper quadrant (asterisk) immediately
lateral to fourth portion of duodenum (arrowhead).
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Fig. 3C. —41-year-old man who complained of midabdominal pain and
nausea. Delayed radiograph of small bowel shows stasis of barium in herniated
loops (double arrowhead). Left-sided paraduodenal hernia was found at
surgery.
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On CT, additional helpful information can be gathered (Figs.
4A,
4B,
4C and
5A,
5B,
5C) although radiologic
findings can remain nonspecific. However, on CT, the location of the herniated
small-bowel loops is more clearly visualized, lying behind the ascending left
colic artery [6] at the level
of or just above and exterior to the ligament of Treitz
[4]. The presence of clustered
bowel loops positioned between the stomach and the pancreatic tail (Figs.
4A,
4B, and
4C), behind the pancreatic
tail (Figs. 5A,
5B, and
5C), or between the transverse
colon and the left adrenal gland
[7,
8] has been reported in
left-sided paraduodenal hernia, although such findings are nonspecific. One
must search for additional signs of bowel complications: small-bowel
obstruction (Fig. 4B), vessel
engorgement (Fig. 5B), or even
acute small-bowel ischemia, including bowel-wall thickening, spontaneous
bowel-wall hyperdensity, mesenteric fluid, the absence of parietal enhancement
after contrast injection, or the presence of parietal air
[9].
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Fig. 4A. —37-year-old man who presented with intense abdominal pain and
vomiting. Contrast-enhanced CT scan shows clustered dilated jejunal loops
(asterisk) displacing posterior duodenal wall (arrowhead)
anteriorly.
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Fig. 4B. —37-year-old man who presented with intense abdominal pain and
vomiting. Contrast-enhanced CT scan obtained at lower level than (A)
confirms dilatation of jejunal loops with visualization of air–fluid
levels (arrowhead).
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Fig. 4C. —37-year-old man who presented with intense abdominal pain and
vomiting. Contrast-enhanced CT scan obtained at duodenojejunal junction shows
abnormal course of mesenteric vessels (arrow) through paraduodenal
fossa. Left-sided paraduodenal hernia was found at surgery.
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Fig. 5A. —59-year-old woman who presented with acute onset of mid upper
abdominal pain. Contrast-enhanced CT scan of upper abdomen shows clustering of
jejunal loops (asterisk) with anterior displacement of pancreatic
body (arrowhead).
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Fig. 5B. —59-year-old woman who presented with acute onset of mid upper
abdominal pain. Contrast-enhanced CT scan shows herniation of small-bowel
loops (asterisk) extending toward descending mesocolon
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Fig. 5C. —59-year-old woman who presented with acute onset of mid upper
abdominal pain. Contrast-enhanced CT scan reveals abnormal disposition of
mesentery (arrowhead) marked by fat and vessels close to trapped
loops. Left-sided paraduodenal hernia was found at surgery.
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Right-Sided Paraduodenal Hernias
Right-sided paraduodenal hernias are congenital disorders that may be
related to the incomplete or absent 180° rotation of the embryologic
midgut. Thus, the proximal portion of the small bowel remains positioned to
the right of the superior mesenteric artery and may possibly be trapped in a
peritoneal pocket within Waldeyer's fossa
[10]. This abnormal peritoneal
recess, which is caused by a defect in the proximal jejunal mesentery, is
rare, observed in no more than 1% of the population at autopsy
[5]. In right-sided
paraduodenal hernias, the entrapped small-bowel loops protrude through this
peritoneal recess behind the superior mesenteric artery toward the right-sided
mesocolon (Fig. 6).
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Fig. 6. —In drawing depicting formation of right-sided paraduodenal
hernia, small-bowel loops are seen herniating through Waldeyer's fossa toward
ascending mesocolon. Note position of superior mesenteric artery in anterior
margin of neck of hernial sac. (Reprinted with permission from
[1])
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The typical clinical presentations of right- and left-sided paraduodenal
hernias are similar; however, both conventional barium studies and CT can be
used to distinguish between the two. In right-sided paraduodenal hernias,
clustered and dilated small-bowel loops are located just lateral and inferior
to the second portion of the duodenum
(Fig. 7). CT can usually
confirm the retroperitoneal topography of the herniated loops (Figs.
8A,
8B,
8C and
9A,
9B). Right-sided paraduodenal
hernias are best identified as clustered small-bowel loops positioned in
Waldeyer's fossa. Rare cases of right ureter compression have been reported
[11]. Furthermore, the
herniated loops and the abnormally located arterial jejunal branches lie
behind either the superior mesenteric artery itself or branches of the
ileocolic artery [10].
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Fig. 7. —63-year-old man who presented with mid and upper abdominal
pain and nausea that had increased in intensity over preceding 2 days.
Radiograph from small-bowel series shows ovoid grouping of jejunal loops
(asterisk) in right mid abdomen. Right-sided paraduodenal hernia was
found at surgery.
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Fig. 8A. —57-year-old man who presented with intense abdominal pain and
vomiting. Asterisk indicates small-bowel loop. Contrast-enhanced CT scan of
upper abdomen suggests presence of right-sided paraduodenal hernia: Distended
small-bowel loop with air–fluid level protrudes behind second portion of
duodenum.
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Fig. 8B. —57-year-old man who presented with intense abdominal pain and
vomiting. Asterisk indicates small-bowel loop. Contrast-enhanced CT scan
reveals protrusion of herniated loops (arrowhead) through Waldeyer's
fossa lateral to second portion of duodenum.
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Fig. 8C. —57-year-old man who presented with intense abdominal pain and
vomiting. Asterisk indicates small-bowel loop. Contrast-enhanced CT scan
reveals position of major mesenteric vessels, particularly superior mesenteric
artery (arrow) located at anterior margin of neck of hernial sac.
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Fig. 9A. —32-year-old man whose clinical symptoms suggested small-bowel
obstruction. Contrast-enhanced CT scan of abdomen reveals presence of large
right-sided paraduodenal hernia marked by clustering and encapsulation of
small-bowel loops (asterisk) in right mid abdomen.
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Fig. 9B. —32-year-old man whose clinical symptoms suggested small-bowel
obstruction. Contrast-enhanced CT scan reveals that superior mesenteric artery
(arrow) is anterior to and compressed by herniated loops
(asterisk). Right-sided paraduodenal hernia was confirmed at
surgery.
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Internal Abdominal Hernias Through the Foramen of Winslow
The mechanism of internal hernias protruding through the foramen of Winslow
is distinct from that of paraduodenal hernias because the foramen of Winslow
is a normal peritoneal opening allowing a communication between the lesser sac
and the remainder of the peritoneal cavity. The foramen is situated in the
portacaval space lying between the portal vein anteriorly and the inferior
vena cava posteriorly (Fig.
10A).
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Fig. 10A. —45-year-old man with acute onset of midabdominal pain and
nausea. Contrast-enhanced CT scan of upper abdomen reveals distended
portacaval space between inferior vena cava (black arrowhead) and
portal trunk (white arrowhead) that has been replaced by mesenteric
fat and vessels.
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An enlarged foramen of Winslow and an excessively long mesentery are the
usual reported predisposing factors for hernias through the foramen of
Winslow. Herniated bowel sections usually involve the small bowel alone (>
60% of all cases), but herniations of the cecum, transverse colon, or
gallbladder have also been reported
[12–15].
Radiographic features of internal abdominal herniations through the foramen of
Winslow can vary depending on which of the organs are entrapped. Direct
radiographic signs include the presence of mesenteric fat and dilated proximal
small-bowel segments protruding into the lesser sac, thus displacing the
stomach laterally and to the front (Figs.
10A,
10B, and
10C). CT allows the
identification of the abnormally located herniated loops in the lesser sac
(Figs. 10A,
10B, and
10C). In all cases, the
position of the cecum and the gallbladder must be assessed, preferably on CT,
because both organs can also protrude through the foramen of Winslow
[15].
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Fig. 10B. —45-year-old man with acute onset of midabdominal pain and
nausea. Contrast-enhanced CT scan reveals protrusion of abnormally located
bowel loops marked by air–fluid levels (arrowhead) through
epiploic foramen of Winslow.
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Fig. 10C. —45-year-old man with acute onset of midabdominal pain and
nausea. Scout radiograph shows clustering of small-bowel loops
(arrow) in upper mid abdomen with lateral displacement of stomach
(S).
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Pericecal Hernias
Pericecal hernias account for only 6–13% of internal abdominal
herniations [5,
16]. Although this type of
hernia is called by various names—ileocolic, retrocecal, ileocecal, or
paracecal hernia—we prefer to refer it as a pericecal hernia because the
diagnostic features and surgical treatment of the four subtypes do not
differ.
The pericecal fossa is located just behind the cecum and ascending colon
and is limited by the parietocecal fold outwards and the mesentericocecal fold
inwards. Most pericecal hernias involve an ileal segment protruding through a
defective cecal mesentery into the pericecal fossa and extending toward the
right paracolic gutter.
Clinical symptoms related to pericecal hernias are usually reported as
recurrent episodes of intense lower abdominal pain that are sometimes
difficult to differentiate from appendiceal pain, but a recent review stressed
the high incidence of occlusive symptoms in pericecal hernias
[16]. Once again, a definite
diagnosis before surgery can confidently be achieved via radiographic
examinations. On barium enema or CT examinations, pericecal hernias are
identified as clustered fixed and dilated small-bowel loops posterior and
lateral relative to the normal cecum and possibly extending into the right
paracolic gutter.
Intersigmoid Hernias
Intersigmoid hernias develop when herniated viscera protrude into a
peritoneal pocket formed between two adjacent sigmoid segments and their
mesentery, the intersigmoid fossa. Radiographic features of intersigmoid
hernias include ileal segments herniated between sigmoid loops (Figs.
11 and
12).
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Fig. 11. —41-year-old woman who reported progressive onset of mild
abdominal discomfort and diarrhea. Radiograph from small-bowel study shows
distended small-bowel loop (arrowhead) trapped between sigmoid loops
(arrow). Intersigmoid hernia was confirmed at surgery.
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Fig. 12. —67-year-old woman who presented with mild fever and
left-sided abdominal pain. Contrast-enhanced CT scan shows presence of
encapsulated fluid-filled and markedly distended bowel loops
(asterisk) protruding toward left lower abdomen through intersigmoid
fossa accompanied by fat and mesenteric vessels (arrow). Intersigmoid
hernia was confirmed at surgery.
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Some authors [5] believe
that intersigmoid hernias should be distinguished from both transmesosigmoid
hernias and intramesosigmoid hernias. In transmesosigmoid hernias, segments of
the small bowel herniate through a complete defect of the sigmoid mesentery
and become encased in a location lateral to the sigmoid. In intramesosigmoid
hernias, an incomplete defect of the mesentery causes a herniation of
small-bowel segments through the mesosigmoid. No clear radiographic sign
allows one to distinguish among the three types of intersigmoid hernias, and
no precise radiologic differentiation is required because surgical exploration
of these hernias is mandatory.
Transmesenteric Hernias
Although accounting for only 5–10% of internal abdominal herniations
overall, transmesenteric hernias are the leading cause of internal abdominal
herniations in children [17].
Most transmesenteric hernias in children result from a congenital defect in
the small-bowel mesentery close to the ileocecal region, whereas in adults,
transmesenteric hernias are most often caused by previous surgical procedures.
In all cases of transmesenteric hernias, no hernial sac can be identified, so
distinguishing between a transmesenteric hernia and a small-bowel volvulus can
be difficult. A recent review has highlighted the high incidence of
transmesenteric hernias after abdominal surgery, especially after the creation
of a Roux-en-Y anastomosis [4].
Clinical symptoms often include signs of acute small-bowel obstruction
(Fig. 13). Radiologic features
include the classic "closed loop" sign reported by Ghahremani
[5].
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Fig. 13. —37-year-old man whose abdominal pain had progressively
increased over preceding 24 hr. Contrast-enhanced CT scan of lower abdomen
suggests presence of transmesenteric hernia. Encapsulated fluid-filled and
markedly distended bowel loops (arrow) protrude toward left abdomen
through defect in mesentery (asterisk), which contains peritoneal
fluid. Acute arterial ischemia of small bowel caused by transmesenteric hernia
was found at surgery.
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Paravesical Hernias
Supravesical hernias, although rare, are the cause of most pelvic hernias.
Approximately 60 cases of supravesical hernias have been reported to date
[18]. Herniation occurs in the
supravesical fossa between the remaining segments of the medial, right, or
left umbilical segments. Herniated bowel loops can either remain within or
extend above the pelvis. Hernias protruding through the broad ligament are
frequently observed in older patients, and most often involve ileal segments.
CT is currently the best imaging technique for detecting these particular
hernias (Fig. 14).
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Fig. 14. —65-year-old woman with lower abdominal pain and mild fever
resulting from paravesical hernia. Contrast-enhanced CT scan of pelvis shows
herniation of small-bowel loops through left broad ligament. Thickened and
hypodense walls of entrapped bowel loops with fluid in pouch of Douglas
suggest bowel-wall ischemia. Note anterior displacement of left broad ligament
(arrowhead).
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Conclusion
Internal abdominal herniations are rare conditions caused by congenital
mesenteric defects or abnormal embryologic development including small-bowel
malrotation. Typical clinical presentation for all forms of internal abdominal
herniations is identical, but prompt diagnosis is mandatory because
small-bowel damage, ischemia, and necrosis can result from misdiagnosis and
consequent delay in proper treatment. CT allows physicians to make a precise
anatomic diagnosis and to identify acute complications; therefore, we highly
recommended obtaining CT scans before laparoscopy is performed.
Acknowledgments
We thank the members of Groupe d'Etude Radiologique des Maladies de
l'Appareil Digestif (GERMAD): Serge Agostini, Christophe Becker, Jean Michel
Bigot, Franck Boudghene, Patrice Bret, Pierre Bret, Jean Michel Bruel, Alain
Dubreuil, Louis Engelholm, Yves Gandon, Gilles Genin, Claude Guien, Louis
Jourde, Robin Lecesne, Claude L'Hermine, Pierre Mahieu, Yves Menu, Maurice
Piante, Eric Ponette, Jacques Pringot, Denis Regent, Michel Rioux,
Gérard Schmutz, Pierre Jean Valette, Bernard Van Beers, and
Valérie Vilgrain.
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Introduction
Classification
