DOI: 10.1148/rg.254045035
CT of Internal Hernias1
Nobuyuki Takeyama, MD,
Takehiko Gokan, MD,
Yoshimitsu Ohgiya, MD,
Shuichi Satoh, MD,
Takashi Hashizume, MD,
Kiyoshi Hataya, MD,
Hiroshi Kushiro, MD,
Makoto Nakanishi, MD,
Mitsuo Kusano, MD and
Hirotsugu Munechika, MD
1 From the Departments of Radiology (N.T., T.G., Y.O., T.H., H.M.) and General and Gastrointestinal Surgery (M.K.), Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8666, Japan; the Departments of Radiology (S.S.) and Surgery (K.H.), Yokohama Asahi Chuo General Hospital, Yokohama, Japan; the Department of Surgery, Kikuna Memorial Hospital, Yokohama, Japan (H.K.); and the Department of Surgery, Totsuka Kyouritsu Hospital, Yokohama, Japan (M.N.). Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA Annual Meeting. Received March 12, 2004; revision requested April 8; final revision received September 30; accepted October 5. All authors have no financial relationships to disclose.
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Figure 1. Drawing (coronal view) shows the locations and directions of internal hernias of the upper and lower abdominal peritoneal cavity. A = foramen of Winslow hernia, B = left paraduodenal hernia, C = right paraduodenal hernia, D = transmesenteric hernia, E = pericecal hernia, F = transomental hernia, G = intersigmoid hernia. (Adapted and reprinted, with permission, from reference 6.)
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Figure 2. Drawing (superior view) shows the locations of internal hernias, pouches, and fossae of the pelvic cavity in a female patient. H = supravesical hernia, I = hernia through the broad ligament, 1 = vesicouterine pouch, 2 = Douglas (rectouterine) pouch, 3 = perirectal fossa. (Adapted and reprinted, with permission, from reference 7.)
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Figure 3a. Foramen of Winslow hernia in a 45-year-old man with acute epigastric pain of 18 hours duration. (a) Abdominal radiograph shows gas-containing small bowel loops (arrows) in the center of the upper abdomen between the liver and the gastric air bubble. (b) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO at the right hepatic flexure (arrow). (c) Contrast-enhanced CT scan of the upper abdomen shows the cluster of dilated small bowel loops (arrowheads) in the lesser sac. There are stretched and converging mesenteric vessels (arrow) between the portal vein in the hepatoduodenal ligament (H) and the inferior vena cava (I). (d) CT scan obtained at the level of the pancreatic head shows crowded mesenteric vessels from the superior mesenteric vein (arrow) between the ascending portion of the duodenum (D) and the pancreatic head (P). Arrowheads = small bowel loops. At laparotomy performed 31 hours after CT, adhesion between the gastrocolic ligament and the transverse mesocolon was found. Approximately 50 cm of ileum, located 200 cm from the ligament of Treitz, was herniated into the lesser sac. The herniated ileal loops demonstrated only congestive changes without gangrene.
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Figure 3b. Foramen of Winslow hernia in a 45-year-old man with acute epigastric pain of 18 hours duration. (a) Abdominal radiograph shows gas-containing small bowel loops (arrows) in the center of the upper abdomen between the liver and the gastric air bubble. (b) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO at the right hepatic flexure (arrow). (c) Contrast-enhanced CT scan of the upper abdomen shows the cluster of dilated small bowel loops (arrowheads) in the lesser sac. There are stretched and converging mesenteric vessels (arrow) between the portal vein in the hepatoduodenal ligament (H) and the inferior vena cava (I). (d) CT scan obtained at the level of the pancreatic head shows crowded mesenteric vessels from the superior mesenteric vein (arrow) between the ascending portion of the duodenum (D) and the pancreatic head (P). Arrowheads = small bowel loops. At laparotomy performed 31 hours after CT, adhesion between the gastrocolic ligament and the transverse mesocolon was found. Approximately 50 cm of ileum, located 200 cm from the ligament of Treitz, was herniated into the lesser sac. The herniated ileal loops demonstrated only congestive changes without gangrene.
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Figure 3c. Foramen of Winslow hernia in a 45-year-old man with acute epigastric pain of 18 hours duration. (a) Abdominal radiograph shows gas-containing small bowel loops (arrows) in the center of the upper abdomen between the liver and the gastric air bubble. (b) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO at the right hepatic flexure (arrow). (c) Contrast-enhanced CT scan of the upper abdomen shows the cluster of dilated small bowel loops (arrowheads) in the lesser sac. There are stretched and converging mesenteric vessels (arrow) between the portal vein in the hepatoduodenal ligament (H) and the inferior vena cava (I). (d) CT scan obtained at the level of the pancreatic head shows crowded mesenteric vessels from the superior mesenteric vein (arrow) between the ascending portion of the duodenum (D) and the pancreatic head (P). Arrowheads = small bowel loops. At laparotomy performed 31 hours after CT, adhesion between the gastrocolic ligament and the transverse mesocolon was found. Approximately 50 cm of ileum, located 200 cm from the ligament of Treitz, was herniated into the lesser sac. The herniated ileal loops demonstrated only congestive changes without gangrene.
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Figure 3d. Foramen of Winslow hernia in a 45-year-old man with acute epigastric pain of 18 hours duration. (a) Abdominal radiograph shows gas-containing small bowel loops (arrows) in the center of the upper abdomen between the liver and the gastric air bubble. (b) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO at the right hepatic flexure (arrow). (c) Contrast-enhanced CT scan of the upper abdomen shows the cluster of dilated small bowel loops (arrowheads) in the lesser sac. There are stretched and converging mesenteric vessels (arrow) between the portal vein in the hepatoduodenal ligament (H) and the inferior vena cava (I). (d) CT scan obtained at the level of the pancreatic head shows crowded mesenteric vessels from the superior mesenteric vein (arrow) between the ascending portion of the duodenum (D) and the pancreatic head (P). Arrowheads = small bowel loops. At laparotomy performed 31 hours after CT, adhesion between the gastrocolic ligament and the transverse mesocolon was found. Approximately 50 cm of ileum, located 200 cm from the ligament of Treitz, was herniated into the lesser sac. The herniated ileal loops demonstrated only congestive changes without gangrene.
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Figure 4. Drawing (coronal view) shows the locations of duodenal fossae. Arrows indicate the directions of hernias through these fossae. The frequency with which each fossa is found at autopsy is given in parentheses. 1 = superior duodenal fossa (50%), 2 = inferior duodenal fossa (fossa of Treitz) (75%), 3 = paraduodenal fossa (fossa of Landzert) (2%), 4 = intermesocolic fossa (fossa of Broesike), 5 = mesentericoparietal fossa (fossa of Waldeyer) (1%). (Adapted and reprinted, with permission, from reference 6.)
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Figure 5a. Left PDH in a 72-year-old man with acute, intermittent epigastric pain of 24 hours duration. (a) Contrast-enhanced CT scan of the upper abdomen shows a saclike mass of dilated jejunal loops between the pancreatic head (P) and stomach. The descending mesocolon (D) and stomach are displaced laterally. The dilated inferior mesenteric vein is located at the anterior border of the encapsulated loops. (b) CT scan obtained 20 mm below a shows crowded and engorged mesenteric vessels (arrow) at the fossa of Landzert (L). J = jejunal loops, S = stomach, arrowhead = inferior mesenteric vein. (c) CT scan of the midabdomen shows the inferior mesenteric vein (arrowhead). This vessel is a landmark for the inferior mesocolon, which is located at the anteromedial border of the encapsulated jejunal loops (J). (d) Diagram (coronal view) of the surgical findings shows that the fossa of Landzert is 4 cm in diameter (arrowheads). At laparotomy performed 42 hours after CT, approximately 200 cm of viable jejunum was found (arrows).
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Figure 5b. Left PDH in a 72-year-old man with acute, intermittent epigastric pain of 24 hours duration. (a) Contrast-enhanced CT scan of the upper abdomen shows a saclike mass of dilated jejunal loops between the pancreatic head (P) and stomach. The descending mesocolon (D) and stomach are displaced laterally. The dilated inferior mesenteric vein is located at the anterior border of the encapsulated loops. (b) CT scan obtained 20 mm below a shows crowded and engorged mesenteric vessels (arrow) at the fossa of Landzert (L). J = jejunal loops, S = stomach, arrowhead = inferior mesenteric vein. (c) CT scan of the midabdomen shows the inferior mesenteric vein (arrowhead). This vessel is a landmark for the inferior mesocolon, which is located at the anteromedial border of the encapsulated jejunal loops (J). (d) Diagram (coronal view) of the surgical findings shows that the fossa of Landzert is 4 cm in diameter (arrowheads). At laparotomy performed 42 hours after CT, approximately 200 cm of viable jejunum was found (arrows).
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Figure 5c. Left PDH in a 72-year-old man with acute, intermittent epigastric pain of 24 hours duration. (a) Contrast-enhanced CT scan of the upper abdomen shows a saclike mass of dilated jejunal loops between the pancreatic head (P) and stomach. The descending mesocolon (D) and stomach are displaced laterally. The dilated inferior mesenteric vein is located at the anterior border of the encapsulated loops. (b) CT scan obtained 20 mm below a shows crowded and engorged mesenteric vessels (arrow) at the fossa of Landzert (L). J = jejunal loops, S = stomach, arrowhead = inferior mesenteric vein. (c) CT scan of the midabdomen shows the inferior mesenteric vein (arrowhead). This vessel is a landmark for the inferior mesocolon, which is located at the anteromedial border of the encapsulated jejunal loops (J). (d) Diagram (coronal view) of the surgical findings shows that the fossa of Landzert is 4 cm in diameter (arrowheads). At laparotomy performed 42 hours after CT, approximately 200 cm of viable jejunum was found (arrows).
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Figure 5d. Left PDH in a 72-year-old man with acute, intermittent epigastric pain of 24 hours duration. (a) Contrast-enhanced CT scan of the upper abdomen shows a saclike mass of dilated jejunal loops between the pancreatic head (P) and stomach. The descending mesocolon (D) and stomach are displaced laterally. The dilated inferior mesenteric vein is located at the anterior border of the encapsulated loops. (b) CT scan obtained 20 mm below a shows crowded and engorged mesenteric vessels (arrow) at the fossa of Landzert (L). J = jejunal loops, S = stomach, arrowhead = inferior mesenteric vein. (c) CT scan of the midabdomen shows the inferior mesenteric vein (arrowhead). This vessel is a landmark for the inferior mesocolon, which is located at the anteromedial border of the encapsulated jejunal loops (J). (d) Diagram (coronal view) of the surgical findings shows that the fossa of Landzert is 4 cm in diameter (arrowheads). At laparotomy performed 42 hours after CT, approximately 200 cm of viable jejunum was found (arrows).
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Figure 6a. Left PDH in a 55-year-old woman who experienced aggravated epigastric pain followed by 3 months of frequent and intermittent pain. (a) Contrast-enhanced CT scan of the upper abdomen shows a sac-like mass of proximal jejunal loops (J). In this case, CT did not show the inferior mesenteric vein, which is a landmark for left PDH. (b) CT scan obtained 30 mm below a shows a horseshoelike configuration of collapsed jejunal loops (arrowheads) and dilated mesenteric vessels (arrow) between the pancreas (P) and stomach (S) without mass effect. At laparotomy performed 7 hours after CT, the herniated jejunal loops were viable with no gangrene.
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Figure 6b. Left PDH in a 55-year-old woman who experienced aggravated epigastric pain followed by 3 months of frequent and intermittent pain. (a) Contrast-enhanced CT scan of the upper abdomen shows a sac-like mass of proximal jejunal loops (J). In this case, CT did not show the inferior mesenteric vein, which is a landmark for left PDH. (b) CT scan obtained 30 mm below a shows a horseshoelike configuration of collapsed jejunal loops (arrowheads) and dilated mesenteric vessels (arrow) between the pancreas (P) and stomach (S) without mass effect. At laparotomy performed 7 hours after CT, the herniated jejunal loops were viable with no gangrene.
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Figure 7a. Right PDH in a 31-year-old man with sudden onset of severe diffuse abdominal pain. (a) Contrast-enhanced CT scan of the upper abdomen shows a saclike mass of fluid-filled bowel loops (S), most of which were jejunal and proximal ileal loops. (b) CT scan obtained 30 mm below a shows the encapsulated bowel loops herniated through the fossa of Waldeyer (W), which is located behind the superior mesenteric artery (arrowhead) just below the transverse portion of the duodenum (D). I = ileal loops. (c) CT scan of the lower abdomen shows the superior mesenteric artery (arrowhead), which is displaced anteriorly by the entrapped bowel loops. Dilated and converging vessels (arrows) are seen in the mesentery; dilated ileal loops (I) are seen in the left midabdomen. (d) Diagram (coronal view) of the surgical findings shows that the fossa of Waldeyer (light gray area) is 10 cm in diameter. At laparotomy performed 2 hours after CT, 350 cm of strangulated small intestine, located 70 cm from the ligament of Treitz, was found. Because the withdrawn bowel loops were purple, jejunostomy was performed without resection.
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Figure 7b. Right PDH in a 31-year-old man with sudden onset of severe diffuse abdominal pain. (a) Contrast-enhanced CT scan of the upper abdomen shows a saclike mass of fluid-filled bowel loops (S), most of which were jejunal and proximal ileal loops. (b) CT scan obtained 30 mm below a shows the encapsulated bowel loops herniated through the fossa of Waldeyer (W), which is located behind the superior mesenteric artery (arrowhead) just below the transverse portion of the duodenum (D). I = ileal loops. (c) CT scan of the lower abdomen shows the superior mesenteric artery (arrowhead), which is displaced anteriorly by the entrapped bowel loops. Dilated and converging vessels (arrows) are seen in the mesentery; dilated ileal loops (I) are seen in the left midabdomen. (d) Diagram (coronal view) of the surgical findings shows that the fossa of Waldeyer (light gray area) is 10 cm in diameter. At laparotomy performed 2 hours after CT, 350 cm of strangulated small intestine, located 70 cm from the ligament of Treitz, was found. Because the withdrawn bowel loops were purple, jejunostomy was performed without resection.
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Figure 7c. Right PDH in a 31-year-old man with sudden onset of severe diffuse abdominal pain. (a) Contrast-enhanced CT scan of the upper abdomen shows a saclike mass of fluid-filled bowel loops (S), most of which were jejunal and proximal ileal loops. (b) CT scan obtained 30 mm below a shows the encapsulated bowel loops herniated through the fossa of Waldeyer (W), which is located behind the superior mesenteric artery (arrowhead) just below the transverse portion of the duodenum (D). I = ileal loops. (c) CT scan of the lower abdomen shows the superior mesenteric artery (arrowhead), which is displaced anteriorly by the entrapped bowel loops. Dilated and converging vessels (arrows) are seen in the mesentery; dilated ileal loops (I) are seen in the left midabdomen. (d) Diagram (coronal view) of the surgical findings shows that the fossa of Waldeyer (light gray area) is 10 cm in diameter. At laparotomy performed 2 hours after CT, 350 cm of strangulated small intestine, located 70 cm from the ligament of Treitz, was found. Because the withdrawn bowel loops were purple, jejunostomy was performed without resection.
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Figure 7d. Right PDH in a 31-year-old man with sudden onset of severe diffuse abdominal pain. (a) Contrast-enhanced CT scan of the upper abdomen shows a saclike mass of fluid-filled bowel loops (S), most of which were jejunal and proximal ileal loops. (b) CT scan obtained 30 mm below a shows the encapsulated bowel loops herniated through the fossa of Waldeyer (W), which is located behind the superior mesenteric artery (arrowhead) just below the transverse portion of the duodenum (D). I = ileal loops. (c) CT scan of the lower abdomen shows the superior mesenteric artery (arrowhead), which is displaced anteriorly by the entrapped bowel loops. Dilated and converging vessels (arrows) are seen in the mesentery; dilated ileal loops (I) are seen in the left midabdomen. (d) Diagram (coronal view) of the surgical findings shows that the fossa of Waldeyer (light gray area) is 10 cm in diameter. At laparotomy performed 2 hours after CT, 350 cm of strangulated small intestine, located 70 cm from the ligament of Treitz, was found. Because the withdrawn bowel loops were purple, jejunostomy was performed without resection.
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Figure 8a. Transmesenteric hernia in a 36-year-old woman with lower abdominal pain of 10 days duration. She was treated conservatively for 20 days by means of decompression with a nasogastric tube or long intestinal tube, intravenous fluids, and antibiotics because of an undiagnosed SBO. However, the SBO developed despite treatment. (a) Contrast-enhanced CT scan of the midabdomen shows dilated and fluid-filled small bowel loops (S) and crowded and stretched vessels (arrow). (b) CT scan of the pelvis shows crowded and converging vessels (arrow) at the hernial orifice. (c) Image obtained with enteroclysis performed through the intestinal tube shows the SBO (arrow). (d) Diagram (coronal view) of the surgical findings shows that approximately 180 cm of strangulated ileum (arrows), located 5 cm from the ileocecal valve, was herniated through the mesenteric defect (arrowheads). At laparotomy, a segment of gangrenous ileum was resected. (e) Intraoperative photograph shows the hernial orifice, which is oval and 4 cm in diameter.
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Figure 8b. Transmesenteric hernia in a 36-year-old woman with lower abdominal pain of 10 days duration. She was treated conservatively for 20 days by means of decompression with a nasogastric tube or long intestinal tube, intravenous fluids, and antibiotics because of an undiagnosed SBO. However, the SBO developed despite treatment. (a) Contrast-enhanced CT scan of the midabdomen shows dilated and fluid-filled small bowel loops (S) and crowded and stretched vessels (arrow). (b) CT scan of the pelvis shows crowded and converging vessels (arrow) at the hernial orifice. (c) Image obtained with enteroclysis performed through the intestinal tube shows the SBO (arrow). (d) Diagram (coronal view) of the surgical findings shows that approximately 180 cm of strangulated ileum (arrows), located 5 cm from the ileocecal valve, was herniated through the mesenteric defect (arrowheads). At laparotomy, a segment of gangrenous ileum was resected. (e) Intraoperative photograph shows the hernial orifice, which is oval and 4 cm in diameter.
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Figure 8c. Transmesenteric hernia in a 36-year-old woman with lower abdominal pain of 10 days duration. She was treated conservatively for 20 days by means of decompression with a nasogastric tube or long intestinal tube, intravenous fluids, and antibiotics because of an undiagnosed SBO. However, the SBO developed despite treatment. (a) Contrast-enhanced CT scan of the midabdomen shows dilated and fluid-filled small bowel loops (S) and crowded and stretched vessels (arrow). (b) CT scan of the pelvis shows crowded and converging vessels (arrow) at the hernial orifice. (c) Image obtained with enteroclysis performed through the intestinal tube shows the SBO (arrow). (d) Diagram (coronal view) of the surgical findings shows that approximately 180 cm of strangulated ileum (arrows), located 5 cm from the ileocecal valve, was herniated through the mesenteric defect (arrowheads). At laparotomy, a segment of gangrenous ileum was resected. (e) Intraoperative photograph shows the hernial orifice, which is oval and 4 cm in diameter.
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Figure 8d. Transmesenteric hernia in a 36-year-old woman with lower abdominal pain of 10 days duration. She was treated conservatively for 20 days by means of decompression with a nasogastric tube or long intestinal tube, intravenous fluids, and antibiotics because of an undiagnosed SBO. However, the SBO developed despite treatment. (a) Contrast-enhanced CT scan of the midabdomen shows dilated and fluid-filled small bowel loops (S) and crowded and stretched vessels (arrow). (b) CT scan of the pelvis shows crowded and converging vessels (arrow) at the hernial orifice. (c) Image obtained with enteroclysis performed through the intestinal tube shows the SBO (arrow). (d) Diagram (coronal view) of the surgical findings shows that approximately 180 cm of strangulated ileum (arrows), located 5 cm from the ileocecal valve, was herniated through the mesenteric defect (arrowheads). At laparotomy, a segment of gangrenous ileum was resected. (e) Intraoperative photograph shows the hernial orifice, which is oval and 4 cm in diameter.
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Figure 8e. Transmesenteric hernia in a 36-year-old woman with lower abdominal pain of 10 days duration. She was treated conservatively for 20 days by means of decompression with a nasogastric tube or long intestinal tube, intravenous fluids, and antibiotics because of an undiagnosed SBO. However, the SBO developed despite treatment. (a) Contrast-enhanced CT scan of the midabdomen shows dilated and fluid-filled small bowel loops (S) and crowded and stretched vessels (arrow). (b) CT scan of the pelvis shows crowded and converging vessels (arrow) at the hernial orifice. (c) Image obtained with enteroclysis performed through the intestinal tube shows the SBO (arrow). (d) Diagram (coronal view) of the surgical findings shows that approximately 180 cm of strangulated ileum (arrows), located 5 cm from the ileocecal valve, was herniated through the mesenteric defect (arrowheads). At laparotomy, a segment of gangrenous ileum was resected. (e) Intraoperative photograph shows the hernial orifice, which is oval and 4 cm in diameter.
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Figure 9a. Transmesenteric hernia in a 12-year-old girl who experienced 36 hours of diffuse abdominal pain and sudden development of cramps. Abdominal examination showed severe distention and tenderness at the midabdomen. Laboratory investigations revealed a hemoglobin level of 8.4 g/dL. (a) Nonenhanced CT scan of the midabdomen shows diffuse mesenteric fluid and haziness (arrows) and mildly dilated small bowel loops. The attenuation of the intraluminal fluid is increased (arrowheads) because red blood cells may have been released in the lumen. Laparotomy was performed 12 hours after CT. (b) Intraoperative photograph shows the hernial orifice (arrow), which is 3 cm in diameter. Approximately 260 cm of small intestine, located 100 cm from the ileocecal valve, was herniated through the mesenteric defect and twisted 360°; 230 cm was gangrenous and was thus resected.
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Figure 9b. Transmesenteric hernia in a 12-year-old girl who experienced 36 hours of diffuse abdominal pain and sudden development of cramps. Abdominal examination showed severe distention and tenderness at the midabdomen. Laboratory investigations revealed a hemoglobin level of 8.4 g/dL. (a) Nonenhanced CT scan of the midabdomen shows diffuse mesenteric fluid and haziness (arrows) and mildly dilated small bowel loops. The attenuation of the intraluminal fluid is increased (arrowheads) because red blood cells may have been released in the lumen. Laparotomy was performed 12 hours after CT. (b) Intraoperative photograph shows the hernial orifice (arrow), which is 3 cm in diameter. Approximately 260 cm of small intestine, located 100 cm from the ileocecal valve, was herniated through the mesenteric defect and twisted 360°; 230 cm was gangrenous and was thus resected.
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Figure 10a. Transomental hernia in a 76-year-old woman with a 6-day history of lower abdominal pain. (a) Contrast-enhanced CT scan of the pelvis shows a cluster of fluid-filled small bowel loops (arrowheads) with poor or absent enhancement of bowel walls adjacent to the midabdominal wall. The mesenteric vascular pedicle (arrow), which is crowded and engorged with vessels, is observed at the hernial orifice. Laparotomy was performed 3 hours after CT. (b) Diagram (coronal view) of the surgical findings shows that the hernial orifice (arrow) is in the periphery of the greater omentum. (c) Intraoperative photograph shows the hernial orifice (arrowhead). Approximately 80 cm of ileum, located 70 cm from the ileocecal valve, was herniated through the defect; 55 cm was resected due to gangrene (arrows).
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Figure 10b. Transomental hernia in a 76-year-old woman with a 6-day history of lower abdominal pain. (a) Contrast-enhanced CT scan of the pelvis shows a cluster of fluid-filled small bowel loops (arrowheads) with poor or absent enhancement of bowel walls adjacent to the midabdominal wall. The mesenteric vascular pedicle (arrow), which is crowded and engorged with vessels, is observed at the hernial orifice. Laparotomy was performed 3 hours after CT. (b) Diagram (coronal view) of the surgical findings shows that the hernial orifice (arrow) is in the periphery of the greater omentum. (c) Intraoperative photograph shows the hernial orifice (arrowhead). Approximately 80 cm of ileum, located 70 cm from the ileocecal valve, was herniated through the defect; 55 cm was resected due to gangrene (arrows).
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Figure 10c. Transomental hernia in a 76-year-old woman with a 6-day history of lower abdominal pain. (a) Contrast-enhanced CT scan of the pelvis shows a cluster of fluid-filled small bowel loops (arrowheads) with poor or absent enhancement of bowel walls adjacent to the midabdominal wall. The mesenteric vascular pedicle (arrow), which is crowded and engorged with vessels, is observed at the hernial orifice. Laparotomy was performed 3 hours after CT. (b) Diagram (coronal view) of the surgical findings shows that the hernial orifice (arrow) is in the periphery of the greater omentum. (c) Intraoperative photograph shows the hernial orifice (arrowhead). Approximately 80 cm of ileum, located 70 cm from the ileocecal valve, was herniated through the defect; 55 cm was resected due to gangrene (arrows).
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Figure 11a. Transomental hernia in a 78-year-old man with acute epigastric pain of 24 hours duration. At admission, the vital signs, laboratory values, and results of physical examination were normal with the exception of mild epigastric pain. On the second hospital day, laboratory investigations showed a white blood cell count of 20,300/mm3 (20.3 x 109/L). (a) Contrast-enhanced CT scan of the midabdomen shows dilated and fluid-filled closed bowel loops (S) surrounded by massive ascites (arrowheads). Engorged and crowded mesenteric vessels (arrow) are seen at the hernial orifice, which is adjacent to the abdominal wall. Laparotomy was performed 2 hours after CT. (b) Diagram (coronal view) of the surgical findings shows that the hernial orifice (arrow) is 3 cm in diameter with a firm and fibrous edge. (c) Intraoperative photograph shows approximately 90 cm of gangrenous jejunal loops (arrows), located 120 cm from the Treitz ligament, which were resected.
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Figure 11b. Transomental hernia in a 78-year-old man with acute epigastric pain of 24 hours duration. At admission, the vital signs, laboratory values, and results of physical examination were normal with the exception of mild epigastric pain. On the second hospital day, laboratory investigations showed a white blood cell count of 20,300/mm3 (20.3 x 109/L). (a) Contrast-enhanced CT scan of the midabdomen shows dilated and fluid-filled closed bowel loops (S) surrounded by massive ascites (arrowheads). Engorged and crowded mesenteric vessels (arrow) are seen at the hernial orifice, which is adjacent to the abdominal wall. Laparotomy was performed 2 hours after CT. (b) Diagram (coronal view) of the surgical findings shows that the hernial orifice (arrow) is 3 cm in diameter with a firm and fibrous edge. (c) Intraoperative photograph shows approximately 90 cm of gangrenous jejunal loops (arrows), located 120 cm from the Treitz ligament, which were resected.
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Figure 11c. Transomental hernia in a 78-year-old man with acute epigastric pain of 24 hours duration. At admission, the vital signs, laboratory values, and results of physical examination were normal with the exception of mild epigastric pain. On the second hospital day, laboratory investigations showed a white blood cell count of 20,300/mm3 (20.3 x 109/L). (a) Contrast-enhanced CT scan of the midabdomen shows dilated and fluid-filled closed bowel loops (S) surrounded by massive ascites (arrowheads). Engorged and crowded mesenteric vessels (arrow) are seen at the hernial orifice, which is adjacent to the abdominal wall. Laparotomy was performed 2 hours after CT. (b) Diagram (coronal view) of the surgical findings shows that the hernial orifice (arrow) is 3 cm in diameter with a firm and fibrous edge. (c) Intraoperative photograph shows approximately 90 cm of gangrenous jejunal loops (arrows), located 120 cm from the Treitz ligament, which were resected.
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Figure 12. Drawing (coronal view) shows the locations of pericecal recesses. 1 = superior ileocecal recess, 2 = inferior ileocecal recess, 3 = retrocecal recess, 4 = paracolic sulci. (Adapted and reprinted, with permission, from reference 41.)
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Figure 13a. Pericecal hernia through the retrocecal recess in an 84-year-old man with colicky right lower quadrant pain and vomiting of 48 hours duration. He underwent an appendectomy at 54 years of age. (a) Contrast-enhanced CT scan of the midabdomen shows a cluster of encapsulated small bowel loops (arrowheads) in the lateral aspect of the right paracolic gutter and behind the ascending colon (A). Dilated and stretched mesenteric vessels (arrow) are seen within the cluster. (b) CT scan of the lower abdomen shows beaking and collapsed bowel loops (arrow) at the retrocecal recess (arrowhead). The ascending colon (A) is displaced anteriorly. Laparotomy was performed 12 hours after CT. (c) Diagram (coronal view) of the surgical findings shows that approximately 230 cm of gangrenous jejunum and ileum (arrows), located 120 cm from the ligament of Treitz, was herniated through the retrocecal recess (arrowheads). The gangrenous bowel loops were resected. A = ascending colon.
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Figure 13b. Pericecal hernia through the retrocecal recess in an 84-year-old man with colicky right lower quadrant pain and vomiting of 48 hours duration. He underwent an appendectomy at 54 years of age. (a) Contrast-enhanced CT scan of the midabdomen shows a cluster of encapsulated small bowel loops (arrowheads) in the lateral aspect of the right paracolic gutter and behind the ascending colon (A). Dilated and stretched mesenteric vessels (arrow) are seen within the cluster. (b) CT scan of the lower abdomen shows beaking and collapsed bowel loops (arrow) at the retrocecal recess (arrowhead). The ascending colon (A) is displaced anteriorly. Laparotomy was performed 12 hours after CT. (c) Diagram (coronal view) of the surgical findings shows that approximately 230 cm of gangrenous jejunum and ileum (arrows), located 120 cm from the ligament of Treitz, was herniated through the retrocecal recess (arrowheads). The gangrenous bowel loops were resected. A = ascending colon.
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Figure 13c. Pericecal hernia through the retrocecal recess in an 84-year-old man with colicky right lower quadrant pain and vomiting of 48 hours duration. He underwent an appendectomy at 54 years of age. (a) Contrast-enhanced CT scan of the midabdomen shows a cluster of encapsulated small bowel loops (arrowheads) in the lateral aspect of the right paracolic gutter and behind the ascending colon (A). Dilated and stretched mesenteric vessels (arrow) are seen within the cluster. (b) CT scan of the lower abdomen shows beaking and collapsed bowel loops (arrow) at the retrocecal recess (arrowhead). The ascending colon (A) is displaced anteriorly. Laparotomy was performed 12 hours after CT. (c) Diagram (coronal view) of the surgical findings shows that approximately 230 cm of gangrenous jejunum and ileum (arrows), located 120 cm from the ligament of Treitz, was herniated through the retrocecal recess (arrowheads). The gangrenous bowel loops were resected. A = ascending colon.
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Figure 14a. Pericecal hernia through the paracolic sulci in an 86-year-old man with a 10-day history of lower abdominal pain and vomiting. He underwent an appendectomy at 56 years of age. (a) Contrast-enhanced CT scan of the lower abdomen shows dilated small bowel loops (S) and a cluster of fluid-filled small bowel loops (arrow). The ascending colon (A) is displaced anteriorly, and ascites (arrowhead) is seen in the right paracolic gutter. (b) CT scan of the pelvis shows that the bowel loops of the oral aspect of the intestine are dilated (arrowhead) and the bowel loops of the anal aspect are collapsed (arrow). Laparotomy was performed 6 hours after CT. (c) Diagram (coronal view) of the surgical findings shows that approximately 20 cm of strangulated ileum (I), located 130 cm from the ileocecal valve, was herniated through a 5-cm-diameter defect of the paracolic sulci (arrow); 10 cm of the incarcerated ileum was resected due to gangrenous changes. A = ascending colon.
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Figure 14b. Pericecal hernia through the paracolic sulci in an 86-year-old man with a 10-day history of lower abdominal pain and vomiting. He underwent an appendectomy at 56 years of age. (a) Contrast-enhanced CT scan of the lower abdomen shows dilated small bowel loops (S) and a cluster of fluid-filled small bowel loops (arrow). The ascending colon (A) is displaced anteriorly, and ascites (arrowhead) is seen in the right paracolic gutter. (b) CT scan of the pelvis shows that the bowel loops of the oral aspect of the intestine are dilated (arrowhead) and the bowel loops of the anal aspect are collapsed (arrow). Laparotomy was performed 6 hours after CT. (c) Diagram (coronal view) of the surgical findings shows that approximately 20 cm of strangulated ileum (I), located 130 cm from the ileocecal valve, was herniated through a 5-cm-diameter defect of the paracolic sulci (arrow); 10 cm of the incarcerated ileum was resected due to gangrenous changes. A = ascending colon.
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Figure 14c. Pericecal hernia through the paracolic sulci in an 86-year-old man with a 10-day history of lower abdominal pain and vomiting. He underwent an appendectomy at 56 years of age. (a) Contrast-enhanced CT scan of the lower abdomen shows dilated small bowel loops (S) and a cluster of fluid-filled small bowel loops (arrow). The ascending colon (A) is displaced anteriorly, and ascites (arrowhead) is seen in the right paracolic gutter. (b) CT scan of the pelvis shows that the bowel loops of the oral aspect of the intestine are dilated (arrowhead) and the bowel loops of the anal aspect are collapsed (arrow). Laparotomy was performed 6 hours after CT. (c) Diagram (coronal view) of the surgical findings shows that approximately 20 cm of strangulated ileum (I), located 130 cm from the ileocecal valve, was herniated through a 5-cm-diameter defect of the paracolic sulci (arrow); 10 cm of the incarcerated ileum was resected due to gangrenous changes. A = ascending colon.
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Figure 15a. Intramesosigmoid hernia in a 79-year-old man with acute lower abdominal pain of 3 hours duration. CT was performed 4 days after conservative treatment with a nasogastric tube. (a, b) Contrast-enhanced CT scans of the pelvis (b obtained 20 mm below a) show multiple dilated small bowel loops (S). A dilated inferior mesenteric vein (arrow) appears as a landmark at the edge of the inferior mesentery. A saclike mass of incarcerated jejunal loops (arrowhead) is located anterior to the left psoas muscle. Laparotomy was performed 4 days after CT. (c) Diagram (coronal view) of the surgical findings shows that 20 cm of jejunum (J), located 230 cm from the ligament of Treitz, was herniated into a defect (arrow) on the left side of the sigmoid mesocolon. The defect was 3 cm in diameter and was located in the anterior layer of the left side of the sigmoid mesocolon.
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Figure 15b. Intramesosigmoid hernia in a 79-year-old man with acute lower abdominal pain of 3 hours duration. CT was performed 4 days after conservative treatment with a nasogastric tube. (a, b) Contrast-enhanced CT scans of the pelvis (b obtained 20 mm below a) show multiple dilated small bowel loops (S). A dilated inferior mesenteric vein (arrow) appears as a landmark at the edge of the inferior mesentery. A saclike mass of incarcerated jejunal loops (arrowhead) is located anterior to the left psoas muscle. Laparotomy was performed 4 days after CT. (c) Diagram (coronal view) of the surgical findings shows that 20 cm of jejunum (J), located 230 cm from the ligament of Treitz, was herniated into a defect (arrow) on the left side of the sigmoid mesocolon. The defect was 3 cm in diameter and was located in the anterior layer of the left side of the sigmoid mesocolon.
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Figure 15c. Intramesosigmoid hernia in a 79-year-old man with acute lower abdominal pain of 3 hours duration. CT was performed 4 days after conservative treatment with a nasogastric tube. (a, b) Contrast-enhanced CT scans of the pelvis (b obtained 20 mm below a) show multiple dilated small bowel loops (S). A dilated inferior mesenteric vein (arrow) appears as a landmark at the edge of the inferior mesentery. A saclike mass of incarcerated jejunal loops (arrowhead) is located anterior to the left psoas muscle. Laparotomy was performed 4 days after CT. (c) Diagram (coronal view) of the surgical findings shows that 20 cm of jejunum (J), located 230 cm from the ligament of Treitz, was herniated into a defect (arrow) on the left side of the sigmoid mesocolon. The defect was 3 cm in diameter and was located in the anterior layer of the left side of the sigmoid mesocolon.
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Figure 16. Drawing (coronal view) shows the anatomy of the broad ligament (B) and various defects. F = fallopian tube, M = mesosalpinx, O = ovary, R = round ligament. (Adapted and reprinted, with permission, from reference 7.)
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Figure 17a. Hernia through the broad ligament in a 51-year-old woman, gravida 2, para 2, with acute lower abdominal pain of 24 hours duration. She had no significant medical history. (a) Contrast-enhanced CT scan of the pelvis shows dilated small bowel loops (S) and a cluster of dilated bowel loops with air-fluid levels (arrow) between the uterus (U) and rectum (R). Stenosis of an incarcerated bowel loop (arrowheads) can be visualized because of the fat layer around the uterus; the C-shaped configuration of the bowel loop suggests a closed-loop obstruction. (b) CT scan obtained 10 mm below a shows that the rectum (R) and sigmoid colon (S) are compressed dorsolaterally and the uterus (U) is compressed ventrally. Arrow = cluster of dilated bowel loops. (c) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO (arrowhead). Laparotomy was performed 11 days after CT. (d) Laparoscopic photograph shows viable distal ileal loops (I) herniated from anterior to posterior through a defect in the left broad ligament (arrows). Resection was not performed.
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Figure 17b. Hernia through the broad ligament in a 51-year-old woman, gravida 2, para 2, with acute lower abdominal pain of 24 hours duration. She had no significant medical history. (a) Contrast-enhanced CT scan of the pelvis shows dilated small bowel loops (S) and a cluster of dilated bowel loops with air-fluid levels (arrow) between the uterus (U) and rectum (R). Stenosis of an incarcerated bowel loop (arrowheads) can be visualized because of the fat layer around the uterus; the C-shaped configuration of the bowel loop suggests a closed-loop obstruction. (b) CT scan obtained 10 mm below a shows that the rectum (R) and sigmoid colon (S) are compressed dorsolaterally and the uterus (U) is compressed ventrally. Arrow = cluster of dilated bowel loops. (c) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO (arrowhead). Laparotomy was performed 11 days after CT. (d) Laparoscopic photograph shows viable distal ileal loops (I) herniated from anterior to posterior through a defect in the left broad ligament (arrows). Resection was not performed.
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Figure 17c. Hernia through the broad ligament in a 51-year-old woman, gravida 2, para 2, with acute lower abdominal pain of 24 hours duration. She had no significant medical history. (a) Contrast-enhanced CT scan of the pelvis shows dilated small bowel loops (S) and a cluster of dilated bowel loops with air-fluid levels (arrow) between the uterus (U) and rectum (R). Stenosis of an incarcerated bowel loop (arrowheads) can be visualized because of the fat layer around the uterus; the C-shaped configuration of the bowel loop suggests a closed-loop obstruction. (b) CT scan obtained 10 mm below a shows that the rectum (R) and sigmoid colon (S) are compressed dorsolaterally and the uterus (U) is compressed ventrally. Arrow = cluster of dilated bowel loops. (c) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO (arrowhead). Laparotomy was performed 11 days after CT. (d) Laparoscopic photograph shows viable distal ileal loops (I) herniated from anterior to posterior through a defect in the left broad ligament (arrows). Resection was not performed.
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Figure 17d. Hernia through the broad ligament in a 51-year-old woman, gravida 2, para 2, with acute lower abdominal pain of 24 hours duration. She had no significant medical history. (a) Contrast-enhanced CT scan of the pelvis shows dilated small bowel loops (S) and a cluster of dilated bowel loops with air-fluid levels (arrow) between the uterus (U) and rectum (R). Stenosis of an incarcerated bowel loop (arrowheads) can be visualized because of the fat layer around the uterus; the C-shaped configuration of the bowel loop suggests a closed-loop obstruction. (b) CT scan obtained 10 mm below a shows that the rectum (R) and sigmoid colon (S) are compressed dorsolaterally and the uterus (U) is compressed ventrally. Arrow = cluster of dilated bowel loops. (c) Image obtained with enteroclysis performed through a long intestinal tube shows an SBO (arrowhead). Laparotomy was performed 11 days after CT. (d) Laparoscopic photograph shows viable distal ileal loops (I) herniated from anterior to posterior through a defect in the left broad ligament (arrows). Resection was not performed.
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Figure 18a. Hernia through a defect of the right perirectal fossa in a 28-year-old woman with continuous lower abdominal pain of 34 hours duration. (a, b) Contrast-enhanced CT scans of the pelvis (b obtained 10 mm below a) show dilated and fluid-filled small bowel loops (S). A cluster of dilated bowel loops (arrow) is located to the right of the rectum (R) and behind the uterine cervix (U). Laparotomy was performed 4 hours after CT. (c) Drawing (superior view) of the surgical findings shows that the antimesenteric wall of an ileal loop (I), located 50 cm from the ileocecal valve, was herniated (Richter hernia) through a defect (arrow) in the anterior peritoneal layer of the right perirectal fossa (arrowheads). When withdrawn manually, the incarcerated bowel loop was viable and nongangrenous. R = rectum, U = uterus.
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Figure 18b. Hernia through a defect of the right perirectal fossa in a 28-year-old woman with continuous lower abdominal pain of 34 hours duration. (a, b) Contrast-enhanced CT scans of the pelvis (b obtained 10 mm below a) show dilated and fluid-filled small bowel loops (S). A cluster of dilated bowel loops (arrow) is located to the right of the rectum (R) and behind the uterine cervix (U). Laparotomy was performed 4 hours after CT. (c) Drawing (superior view) of the surgical findings shows that the antimesenteric wall of an ileal loop (I), located 50 cm from the ileocecal valve, was herniated (Richter hernia) through a defect (arrow) in the anterior peritoneal layer of the right perirectal fossa (arrowheads). When withdrawn manually, the incarcerated bowel loop was viable and nongangrenous. R = rectum, U = uterus.
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Figure 18c. Hernia through a defect of the right perirectal fossa in a 28-year-old woman with continuous lower abdominal pain of 34 hours duration. (a, b) Contrast-enhanced CT scans of the pelvis (b obtained 10 mm below a) show dilated and fluid-filled small bowel loops (S). A cluster of dilated bowel loops (arrow) is located to the right of the rectum (R) and behind the uterine cervix (U). Laparotomy was performed 4 hours after CT. (c) Drawing (superior view) of the surgical findings shows that the antimesenteric wall of an ileal loop (I), located 50 cm from the ileocecal valve, was herniated (Richter hernia) through a defect (arrow) in the anterior peritoneal layer of the right perirectal fossa (arrowheads). When withdrawn manually, the incarcerated bowel loop was viable and nongangrenous. R = rectum, U = uterus.
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Copyright © 2005 by the Radiological Society of North America.
