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Pictorial Essay
Internal Abdominal Herniations
Didier Mathieu1 and Alain Luciani1 for the GERMAD Group2
n 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 nonspecic, 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. Specic signs of internal abdominal herniations on CT have been previously reported [24]. The use of CT could limit the rate of misdiagnosed internal abdominal herniations be-

cause subtle transmesenteric internal abdominal herniations can be difcult 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 ndings on barium as well as CT studies.

which account for 75% of all paraduodenal hernias, and right-sided paraduodenal hernias, which account for the remaining 25% [5].

Classification

The classications of internal abdominal herniations devised by Ghahremani [5] is now well accepted. According to this classication system, internal abdominal herniations can be separated in six main groups (Fig. 1): paraduodenal hernias (5055% of internal abdominal herniations), hernias through the foramen of Winslow (610%), transmesenteric hernias (810%), pericecal hernias (1015%), intersigmoid hernias (48%), and paravesical hernias (< 4%).
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 modied with permission from [5])

Paraduodenal Hernias

Two types of paraduodenal hernias must be distinguished: left-sided paraduodenal hernias,

Received August 1, 2003; accepted after revision January 12, 2004.


1

Services de Radiologie et dImagerie Mdicale, Hpital Henri Mondor, 51 ave. du Marchal de Lattre de Tassigny, Crteil 94010, France. Address correspondence to D. Mathieu (profdm@wanadoo.fr). Groupe dEtude Radiologique des Maladies de lAppareil Digestif (GERMAD), Paris, France

AJR 2004;183:397404 0361803X/04/1832397 American Roentgen Ray Society

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Fig. 2.Illustrations detail development of left-sided paraduodenal hernia. (Reprinted with permission from [1]) A, Small-bowel loops herniate into descending mesocolon through paraduodenal fossa posterior to inferior mesenteric vein and ascending left colic artery. B, Small-bowel loops progressively herniate through abnormal peritoneal pocket. C, Both inferior mesenteric vein and left ascending colic artery always remain anterior to neck of herniated sac in left-sided paraduodenal hernia.

Left-Sided Paraduodenal Hernias

In left-sided paraduodenal hernias (Fig. 2), small-bowel loops herniate into an unusual fossa to the left of the duodenum referred to as the paraduodenal fossa, or Landzerts fossa, that results from a congenital defect in the descending mesocolon. This abnormal perito-

neal 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 Landzerts

fossa, and then extend further in the descending mesocolon. Radiographic ndings of left-sided paraduodenal hernias are well correlated to the anatomic topography. On barium examinations, the typical nding is the presence of a mass of agglomerated small-bowel loops just lateral to the

Fig. 3.41-year-old man who complained of midabdominal pain and nausea. A, Conventional abdominal radiograph obtained with patient supine shows mass in left upper quadrant (asterisk) compressing both stomach (single arrowhead) and transverse colon (double arrowhead). B, 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). C, 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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A
Fig. 4.37-year-old man who presented with intense abdominal pain and vomiting. A, Contrast-enhanced CT scan shows clustered dilated jejunal loops (asterisk) displacing posterior duodenal wall (arrowhead) anteriorly. B, Contrast-enhanced CT scan obtained at lower level than (A) conrms dilatation of jejunal loops with visualization of airuid levels (arrowhead). C, 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.

C fourth portion of the duodenum (Fig. 3) that is separated from the remaining bowel loops and shows signs of obstruction (dilatation of smallbowel loops or barium stasis) (Fig. 3). On CT, additional helpful information can be gathered (Figs. 4 and 5) although radiologic ndings can remain nonspecic. 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 (Fig. 4), behind the pancreatic tail (Fig. 5), or between the transverse colon and the left adrenal gland [7, 8] has been reported in left-sided paraduodenal hernia, although such ndings are nonspecic. 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 uid, the absence of parietal enhancement after contrast injection, or the presence of parietal air [9].
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 Waldeyers 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 supe-

rior mesenteric artery toward the right-sided mesocolon (Fig. 6). The typical clinical presentations of rightand 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 conrm the retroperitoneal topography of the herniated loops (Figs. 8 and 9). Right-sided paraduodenal hernias are best identied as clustered small-bowel loops positioned in Waldeyers 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. 5.59-year-old woman who presented with acute onset of mid upper abdominal pain. A, Contrast-enhanced CT scan of upper abdomen shows clustering of jejunal loops (asterisk) with anterior displacement of pancreatic body (arrowhead). B, Contrast-enhanced CT scan shows herniation of small-bowel loops (asterisk) extending toward descending mesocolon C, 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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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). 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 [1215]. 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 (Fig. 10). CT allows the identication of the abnormally located herniated loops in the lesser sac (Fig. 10). 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].

Pericecal Hernias

Pericecal hernias account for only 613% of internal abdominal herniations [5, 16]. Although this type of hernia is called by various namesileocolic, retrocecal, ileocecal, or paracecal herniawe 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 difcult to differentiate from appendiceal pain, but a recent review stressed the high incidence of occlusive symptoms in pericecal hernias [16]. Once again, a denite diagnosis before surgery can condently be achieved via radiographic examinations. On barium enema or CT examinations, pericecal hernias are identied as clustered xed and dilated small-bowel loops posterior and lateral relative to the normal cecum and possibly extending into the right paracolic gutter.

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Fig. 6.In drawing depicting formation of right-sided paraduodenal hernia, small-bowel loops are seen herniating through Waldeyers 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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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.

Fig. 8.57-year-old man who presented with intense abdominal pain and vomiting. Asterisk indicates small-bowel loop. A, Contrast-enhanced CT scan of upper abdomen suggests presence of right-sided paraduodenal hernia: Distended small-bowel loop with airuid level protrudes behind second portion of duodenum. B, Contrast-enhanced CT scan reveals protrusion of herniated loops (arrowhead) through Waldeyers fossa lateral to second portion of duodenum. C, 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. 9.32-year-old man whose clinical symptoms suggested small-bowel obstruction. A, 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. B, Contrast-enhanced CT scan reveals that superior mesenteric artery (arrow) is anterior to and compressed by herniated loops (asterisk). Right-sided paraduodenal hernia was conrmed at surgery.

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).

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.

Fig. 10.45-year-old man with acute onset of midabdominal pain and nausea. A, 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. B, Contrast-enhanced CT scan reveals protrusion of abnormally located bowel loops marked by airuid levels (arrowhead) through epiploic foramen of Winslow. (Fig. 10 continues on next page)

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Fig. 10. (continued)45-year-old man with acute onset of midabdominal pain and nausea. C, Scout radiograph shows clustering of small-bowel loops (arrow) in upper mid abdomen with lateral displacement of stomach (S).

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Transmesenteric Hernias

Although accounting for only 510% 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 identied, so distinguishing between a transmesenteric hernia and a small-bowel volvulus can be difcult. 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].

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).

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

Conclusion

Internal abdominal herniations are rare conditions caused by congenital mesenteric de-

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 conrmed at surgery.

Fig. 12.67-year-old woman who presented with mild fever and left-sided abdominal pain. Contrast-enhanced CT scan shows presence of encapsulated uid-lled and markedly distended bowel loops (asterisk) protruding toward left lower abdomen through intersigmoid fossa accompanied by fat and mesenteric vessels (arrow). Intersigmoid hernia was conrmed at surgery.

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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 uid-lled and markedly distended bowel loops (arrow) protrude toward left abdomen through defect in mesentery (asterisk), which contains peritoneal uid. Acute arterial ischemia of small bowel caused by transmesenteric hernia was found at surgery.

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 uid in pouch of Douglas suggest bowel-wall ischemia. Note anterior displacement of left broad ligament (arrowhead).

fects 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.

Pierre Jean Valette, Bernard Van Beers, and Valrie Vilgrain.

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Acknowledgments

We thank the members of Groupe dEtude Radiologique des Maladies de lAppareil 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 LHermine, Pierre Mahieu, Yves Menu, Maurice Piante, Eric Ponette, Jacques Pringot, Denis Regent, Michel Rioux, Grard Schmutz,

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