- Email: [email protected]
Congenital internal hernia
Congenital EDWIN C.
Internal MUELLER,
From Tbe Department of Surgery, Tbe Ohio State versity College of Medicine, Columbus, Ohio.
M.D.,
Uni-
Hernia
Columbus, Ohio
and the exact nature of the lesion has been of academic interest onIy since the indication for surgery was clear. Three of our patients had had previous surgery but we beIieve that the evidence cIearIy supports a diagnosis of congenita1 hernia apparentIy not noted at the previous surgery. AI1 three had definite developmenta1 or rotational anomaIies noted at surgery when the diagnosis of interna hernia was established.
T remains
differentia1 diagnosis of abdominal pain one of the most challenging problems confronting physicians. Although not a common Iesion, internal hernia is a cause of abdomina1 pain which is diffrcuh to diagnose. In an attempt to cIarify the clinica picture and to determine whether this diagnosis can be estabIished preoperativeIy I have reviewed the Iiterature and the cases seen at this institution during the past five years. Eight cases of congenita1 interna hernia were seen during the past five years and of these, three were acuteIy obstructed and no further diagnosis made prior to surgery. Four of the remaining five were correctly diagnosed preoperativeIy by the radioIogrsts. HE
CASE
SUMMARIES
Our experience is summarized in TabIe I. None of the three paraduodena1 hernias were acutely obstructed but a11 occurred in aduIts who had symptoms of recurrent crampy upper abdomina1 pain of one to three years’ duration. This was usually worse after eating and a11 patients had vomited on occasion after eating. Two of the three patients had Iost considerable weight. A cIinica1 diagnosis of ChoIecystitis had been made in one instance. The RadioIogy Department was abIe to make the correct diagnosis by upper gastrointestina1 barium study in a11 three cases. There were three cases of congenita1 transmesocoIic hernia, one presenting as acute intestinal obstruction. In the second case, a patient on whom previous peIvic surgery had been performed, there was incompIete rotation of the right colon. The third case was successfuIIy diagnosed by x-ray examination. Two cases of paraceca1 hernia presented as acute intestina1 obstruction with symptoms of one and five days’ duration and were successfuIIy treated surgicaIIy.
ETIOLOGY
The etiology of interna hernia is varied but may generaIIy be stated as congenita1 or acquired. Andrews [I] first noted that most fossa interna hernias are anomaIies of rotation and deveIopment of the mid-gut which eventuaIIy becomes the jejunum, iIeum, and right coIon. CaIIander et a1. [2], Johnson [$I, and Zimmerman and Laufman [9] have studied the etioIogy of congenital interna hernias and beIieve that the hernias resuIt from faiIures of deveIopment, rotation, and apposition. InternaI incarceration can aIso be caused by congenita1 bands or defects without any deveIopmenta1 or rotationa1 anomaIies but these are probabIy not true hernias. The acquired hernias are most frequentIy seen foIlowing surgery with a few reported after trauma and inflammation. It is diffIcuIt to determine the exact nature of many of the acquired or postoperative hernias and therefore these have been omitted from this discussion except for the statement that practicaIIy a11 those seen were operated upon with the diagnosis of acute intestinal obstruction
COMMENTS
The Iiterature on this subject is comprised IargeIy of case reports and the Iargest individua1 series found was that of Mayo, StaIker and MiIIer [7] who reported thirty-nine cases with eighteen congenita1 and twenty-one acquired 201
American
Journal
of Surgery,
Volume
9,.
February,
19s~
MueIIer
FIG. IA. Case II. A congIomcration of barium-IiIIed jejunum is noted to the right of the duodenum indicating a right paraduodena1 hernia. Jejunum is also absent from the Ieft upper quadrant of the abdomen.
FIG. r B. Case II. The IateraI view shows the proxima1 jejuna1 Ioops Iocated posterior and to the right of the duodenum.
postoperative hernias coIIected from Ig Io to 1939. They report acute intestina1 obstruction in nineteen patients and symptoms in a tota of twenty-nine but do not differentiate primary from acquired hernias and do not give any mortality figures. Zimmerman and Laufman [g] reported tweIve
cases of true congenita1 interna hernia found in a ten-year period at the Cook County HospitaI. Surgery was performed in eight of the cases with an operative mortaIity of 37 per cent and an over-a11 mortaIity of 58 per cent. The Iargest coIIective series is that of Hansmann and Morton [4] who coIIected 467 cases and added
Case
Year
Age
TABLE
I
RadioIogist’s
Diagnosis
Diagnosis
_-
I
61
‘952
Right paraduodenal hernia
InternaI
hernia
II
47
I953
Internal
hernia
III
31
1955
InternaI
hernia
IV V
60 48
1954 1954
Right paraduodena1 hernia Right paraduodena1 hernia TransmesocoIic hernia TransmesocoIic hernia
VI
54
I957
TransmesocoIic
InternaI
VII
75
1953
Paracecal
67
I957
ParacecaI
VIII
-
Obstruction
Symptoms
__
hernia
/Obstruction of small
Pain in right upper quadrant postprandial nausea and vomiting Epigastric pain, 30 Ib. weight Ioss PostprandiaI cramps, 30 Ib. weight Ioss Diarrhea Intermittent pain, vomiting ; Intermittent upper abdominal pain Crampy abdomina1 pain
hernia
bowe1 ,Obstruction bowe1
Crampy abdomina1 pain vomiting
“Chronic obstruction” Mechanica obstruction
hernia
hernia
of smaI1
202
No No No Yes No Yes Yes
-
-
No
CongenitaI
InternaI
one of their own but did not state the number treated surgicalIy or the mortaIity. Cutler and Scott [3] coIlected fifty cases of transmesenteric hernia with an overal mortaIity of 38 per cent. Our eight patients were treated surgicaIIy without mortality. Only three cases presented as acute intestinal obstruction requiring emergency surgery and four of the remaining five cases were correctly diagnosed preoperativeIy. It should be mentioned that the standards of preoperative and postoperative care have been raised considerably since many of the cases were reported in the literature. ApparentIy a11tweIve cases reported by Zimmerman and Laufman [g] presented as acute abdominal emergencies and the correct clinica diagnosis was not made in any case. Mayo et a1. 181 state that the diagnosis of duodena1 hernia is a rare feat and Longacre [6] reports the correct diagnosis in onIy five of 140 paraduodena1 hernias. Our experience, aIthough Iimited, wouId indicate that the diagnosis can be made preoperativeIy when suspected in the non-obstructed cases. It shouId be emphasized that chronic, intermittent, crampy abdomina1
Hernia
FIG. 2. Case III. CongIomerate Ioops of jejunum filling the right upper abdomen adjacent to the duodenum indicate a right paraduodena1 hernia.
FIG. 3B. Case VI. LateraI view shows the cIump of smaI1 bowel extending posterior to the posterior vertebra1 border.
FIG. 3A. Case VI. TransmesocoIic hernia studied by barium enema. Note the redundant colon and the conglomeration of small bowe1 loops in the Ieft upper quadrant.
203
MueIIer pain associated with nausea and relieved by vomiting was the presenting complaint in a11 but one of our cases. The presenting compIaint in the remaining case was diarrhea. Barium studies were performed in all five of the unobstructed cases and the diagnosis made in four. WiIliams [8] has anaIyzed the findings on x-ray films in internal hernia and has listed in order of importance displacement or disturbance of smaI1 bowe1 arrangement, saccuIation or cIumping, segmental dilatation, stasis, reversed peristaIsis and fixation. He has stressed examination in the IateraI erect position. These diagnostic features are shown in Figures I through 3. The surgeon must be aware of the various types and Iocations of internal hernias and the anatomy of each to faciIitate their management when encountered. He must ako examine the restraining structures (mesentery, peritonea1 reflections) thoroughIy with respect to the Iocation of defects producing interna hernia whenever the abdomen is expIored for unexplained pain or obstruction remembering that these hernias may reduce spontaneousIy under anesthesia. InternaI hernias may present as acute intestinal obstruction with progressive symptomatoIogy or as a vague syndrome of intermittent and discrampy pain, nausea and vomiting, tention characteristic of incomplete obstruction. Those presenting as acute obstruction are IargeIy of academic interest because the indications for surgery are those of any intestina1 obstruction. AI1 of our cases of acquired interna hernia were diagnosed when explored for obstruction. The congenita1 group may be extremely diffrcuIt to diagnose‘but the diagnosis of congenita1 interna hernia shouId be considered when the patient who has not undergone operation
204
presents with symptoms of intermittent intestinal obstruction-crampy pain, nausea, vomiting, loss of weight. A routine upper gastrointestinal barium study wiI1 demonstrate some of these Iesions but if negative, a study of the smaI1 bowel should be made. SUMMARY
Eight cases of congenita1 interna hernia are presented. Three presented as acute intestina1 obstruction and five as chronic intermittent abdominal pain with the correct diagnosis estabIished by x-ray examination in four cases. AI1 eight cases were corrected by surgery without any mortality. Acknowledgment: I am gratefu1 to Dr. WiIIiam MoInar, Department of RadioIogy, for assistance in selecting and interpreting the x-ray fiIms. REFERENCES ANDREWS, E. Duodenal hernia-a misnomer. Surg., Gyner. CYObst., 37: 740, 1923. CALLANDER,C. L., RUSK, G. Y. and NEIUR, A. 2. Mechanism, symptoms, and treatment of hernia into the descending mesocolon (left duodenal hernia). Surg., Gynec. &+ Obst., 60: 1052: 1935. 3. CUTLER, G. D. and SCOTT, H. W. Transmesenteric hernia. Surg., Gynec. c++Obst., 79: 409, 1944. S. A. Intraabdomi4. HANSMANN,G. H. and MORTON, na1 hernia. Arch. Surg., 39: 973, 1939. hernia. Arch. Surg., 60: I 171, 5. JOHNSON, J. R. Internal '950. hernia. Surg., 6. LONGACRE, J. J. Mesentericoparietal Gynec. Ed Obst., 59: 165, 1934. 7. MAYO, C. W., STALKER,L. K. and MILLER, J. M. Intraabdominal hernia. Ann. Surg., I 14: 875, 1941. diagnosis of intraab8. WILLIAMS, A. J. Roentgen domina1 hernia; an evaluation of the rocntgen frndings. Radiology, 59: 817, 1952. 9- ZIMMERMAN,L. hl. and LAUFMAN, H. Intra-abdominal hernias due to deveIopmenta1 and rotationat anomalies. Ann. Surg., 138: 82, 1953. I.
Internal MUELLER,
From Tbe Department of Surgery, Tbe Ohio State versity College of Medicine, Columbus, Ohio.
M.D.,
Uni-
Hernia
Columbus, Ohio
and the exact nature of the lesion has been of academic interest onIy since the indication for surgery was clear. Three of our patients had had previous surgery but we beIieve that the evidence cIearIy supports a diagnosis of congenita1 hernia apparentIy not noted at the previous surgery. AI1 three had definite developmenta1 or rotational anomaIies noted at surgery when the diagnosis of interna hernia was established.
T remains
differentia1 diagnosis of abdominal pain one of the most challenging problems confronting physicians. Although not a common Iesion, internal hernia is a cause of abdomina1 pain which is diffrcuh to diagnose. In an attempt to cIarify the clinica picture and to determine whether this diagnosis can be estabIished preoperativeIy I have reviewed the Iiterature and the cases seen at this institution during the past five years. Eight cases of congenita1 interna hernia were seen during the past five years and of these, three were acuteIy obstructed and no further diagnosis made prior to surgery. Four of the remaining five were correctly diagnosed preoperativeIy by the radioIogrsts. HE
CASE
SUMMARIES
Our experience is summarized in TabIe I. None of the three paraduodena1 hernias were acutely obstructed but a11 occurred in aduIts who had symptoms of recurrent crampy upper abdomina1 pain of one to three years’ duration. This was usually worse after eating and a11 patients had vomited on occasion after eating. Two of the three patients had Iost considerable weight. A cIinica1 diagnosis of ChoIecystitis had been made in one instance. The RadioIogy Department was abIe to make the correct diagnosis by upper gastrointestina1 barium study in a11 three cases. There were three cases of congenita1 transmesocoIic hernia, one presenting as acute intestinal obstruction. In the second case, a patient on whom previous peIvic surgery had been performed, there was incompIete rotation of the right colon. The third case was successfuIIy diagnosed by x-ray examination. Two cases of paraceca1 hernia presented as acute intestina1 obstruction with symptoms of one and five days’ duration and were successfuIIy treated surgicaIIy.
ETIOLOGY
The etiology of interna hernia is varied but may generaIIy be stated as congenita1 or acquired. Andrews [I] first noted that most fossa interna hernias are anomaIies of rotation and deveIopment of the mid-gut which eventuaIIy becomes the jejunum, iIeum, and right coIon. CaIIander et a1. [2], Johnson [$I, and Zimmerman and Laufman [9] have studied the etioIogy of congenital interna hernias and beIieve that the hernias resuIt from faiIures of deveIopment, rotation, and apposition. InternaI incarceration can aIso be caused by congenita1 bands or defects without any deveIopmenta1 or rotationa1 anomaIies but these are probabIy not true hernias. The acquired hernias are most frequentIy seen foIlowing surgery with a few reported after trauma and inflammation. It is diffIcuIt to determine the exact nature of many of the acquired or postoperative hernias and therefore these have been omitted from this discussion except for the statement that practicaIIy a11 those seen were operated upon with the diagnosis of acute intestinal obstruction
COMMENTS
The Iiterature on this subject is comprised IargeIy of case reports and the Iargest individua1 series found was that of Mayo, StaIker and MiIIer [7] who reported thirty-nine cases with eighteen congenita1 and twenty-one acquired 201
American
Journal
of Surgery,
Volume
9,.
February,
19s~
MueIIer
FIG. IA. Case II. A congIomcration of barium-IiIIed jejunum is noted to the right of the duodenum indicating a right paraduodena1 hernia. Jejunum is also absent from the Ieft upper quadrant of the abdomen.
FIG. r B. Case II. The IateraI view shows the proxima1 jejuna1 Ioops Iocated posterior and to the right of the duodenum.
postoperative hernias coIIected from Ig Io to 1939. They report acute intestina1 obstruction in nineteen patients and symptoms in a tota of twenty-nine but do not differentiate primary from acquired hernias and do not give any mortality figures. Zimmerman and Laufman [g] reported tweIve
cases of true congenita1 interna hernia found in a ten-year period at the Cook County HospitaI. Surgery was performed in eight of the cases with an operative mortaIity of 37 per cent and an over-a11 mortaIity of 58 per cent. The Iargest coIIective series is that of Hansmann and Morton [4] who coIIected 467 cases and added
Case
Year
Age
TABLE
I
RadioIogist’s
Diagnosis
Diagnosis
_-
I
61
‘952
Right paraduodenal hernia
InternaI
hernia
II
47
I953
Internal
hernia
III
31
1955
InternaI
hernia
IV V
60 48
1954 1954
Right paraduodena1 hernia Right paraduodena1 hernia TransmesocoIic hernia TransmesocoIic hernia
VI
54
I957
TransmesocoIic
InternaI
VII
75
1953
Paracecal
67
I957
ParacecaI
VIII
-
Obstruction
Symptoms
__
hernia
/Obstruction of small
Pain in right upper quadrant postprandial nausea and vomiting Epigastric pain, 30 Ib. weight Ioss PostprandiaI cramps, 30 Ib. weight Ioss Diarrhea Intermittent pain, vomiting ; Intermittent upper abdominal pain Crampy abdomina1 pain
hernia
bowe1 ,Obstruction bowe1
Crampy abdomina1 pain vomiting
“Chronic obstruction” Mechanica obstruction
hernia
hernia
of smaI1
202
No No No Yes No Yes Yes
-
-
No
CongenitaI
InternaI
one of their own but did not state the number treated surgicalIy or the mortaIity. Cutler and Scott [3] coIlected fifty cases of transmesenteric hernia with an overal mortaIity of 38 per cent. Our eight patients were treated surgicaIIy without mortality. Only three cases presented as acute intestinal obstruction requiring emergency surgery and four of the remaining five cases were correctly diagnosed preoperativeIy. It should be mentioned that the standards of preoperative and postoperative care have been raised considerably since many of the cases were reported in the literature. ApparentIy a11tweIve cases reported by Zimmerman and Laufman [g] presented as acute abdominal emergencies and the correct clinica diagnosis was not made in any case. Mayo et a1. 181 state that the diagnosis of duodena1 hernia is a rare feat and Longacre [6] reports the correct diagnosis in onIy five of 140 paraduodena1 hernias. Our experience, aIthough Iimited, wouId indicate that the diagnosis can be made preoperativeIy when suspected in the non-obstructed cases. It shouId be emphasized that chronic, intermittent, crampy abdomina1
Hernia
FIG. 2. Case III. CongIomerate Ioops of jejunum filling the right upper abdomen adjacent to the duodenum indicate a right paraduodena1 hernia.
FIG. 3B. Case VI. LateraI view shows the cIump of smaI1 bowel extending posterior to the posterior vertebra1 border.
FIG. 3A. Case VI. TransmesocoIic hernia studied by barium enema. Note the redundant colon and the conglomeration of small bowe1 loops in the Ieft upper quadrant.
203
MueIIer pain associated with nausea and relieved by vomiting was the presenting complaint in a11 but one of our cases. The presenting compIaint in the remaining case was diarrhea. Barium studies were performed in all five of the unobstructed cases and the diagnosis made in four. WiIliams [8] has anaIyzed the findings on x-ray films in internal hernia and has listed in order of importance displacement or disturbance of smaI1 bowe1 arrangement, saccuIation or cIumping, segmental dilatation, stasis, reversed peristaIsis and fixation. He has stressed examination in the IateraI erect position. These diagnostic features are shown in Figures I through 3. The surgeon must be aware of the various types and Iocations of internal hernias and the anatomy of each to faciIitate their management when encountered. He must ako examine the restraining structures (mesentery, peritonea1 reflections) thoroughIy with respect to the Iocation of defects producing interna hernia whenever the abdomen is expIored for unexplained pain or obstruction remembering that these hernias may reduce spontaneousIy under anesthesia. InternaI hernias may present as acute intestinal obstruction with progressive symptomatoIogy or as a vague syndrome of intermittent and discrampy pain, nausea and vomiting, tention characteristic of incomplete obstruction. Those presenting as acute obstruction are IargeIy of academic interest because the indications for surgery are those of any intestina1 obstruction. AI1 of our cases of acquired interna hernia were diagnosed when explored for obstruction. The congenita1 group may be extremely diffrcuIt to diagnose‘but the diagnosis of congenita1 interna hernia shouId be considered when the patient who has not undergone operation
204
presents with symptoms of intermittent intestinal obstruction-crampy pain, nausea, vomiting, loss of weight. A routine upper gastrointestinal barium study wiI1 demonstrate some of these Iesions but if negative, a study of the smaI1 bowel should be made. SUMMARY
Eight cases of congenita1 interna hernia are presented. Three presented as acute intestina1 obstruction and five as chronic intermittent abdominal pain with the correct diagnosis estabIished by x-ray examination in four cases. AI1 eight cases were corrected by surgery without any mortality. Acknowledgment: I am gratefu1 to Dr. WiIIiam MoInar, Department of RadioIogy, for assistance in selecting and interpreting the x-ray fiIms. REFERENCES ANDREWS, E. Duodenal hernia-a misnomer. Surg., Gyner. CYObst., 37: 740, 1923. CALLANDER,C. L., RUSK, G. Y. and NEIUR, A. 2. Mechanism, symptoms, and treatment of hernia into the descending mesocolon (left duodenal hernia). Surg., Gynec. &+ Obst., 60: 1052: 1935. 3. CUTLER, G. D. and SCOTT, H. W. Transmesenteric hernia. Surg., Gynec. c++Obst., 79: 409, 1944. S. A. Intraabdomi4. HANSMANN,G. H. and MORTON, na1 hernia. Arch. Surg., 39: 973, 1939. hernia. Arch. Surg., 60: I 171, 5. JOHNSON, J. R. Internal '950. hernia. Surg., 6. LONGACRE, J. J. Mesentericoparietal Gynec. Ed Obst., 59: 165, 1934. 7. MAYO, C. W., STALKER,L. K. and MILLER, J. M. Intraabdominal hernia. Ann. Surg., I 14: 875, 1941. diagnosis of intraab8. WILLIAMS, A. J. Roentgen domina1 hernia; an evaluation of the rocntgen frndings. Radiology, 59: 817, 1952. 9- ZIMMERMAN,L. hl. and LAUFMAN, H. Intra-abdominal hernias due to deveIopmenta1 and rotationat anomalies. Ann. Surg., 138: 82, 1953. I.