Internal hernia as a rare cause of small bowel obstruction: An insight from 13 years of experience

Table 1 Demographic profile, hallmark radiological feature, and type of internal hernia observed in our patients

Age (in years)/gender	Type/location	Symptom duration	Time of diagnosis	Characteristic imaging finding	Presentation	Intraoperative finding	Follow-up
Congenital internal hernia
35/F	Left PDH	1 year	Intraoperative	None	AIO	Open repair (2013): No intra-peritoneal adhesions. Lenzert’s defect identified. No bowel ischemia/ malrotation	Discharged on POD14. No recurrence. Last follow-up in 2023
32/M	Right PDH	Childhood	Preoperative	Clumped-up bowel loops in right lumbar region	CIO	Laparoscopic repair (2014): Dilated stomach and proximal duodenum with duodeno-jejunal flexure to the right of midline suggesting malroation. Entire small bowel formed the content of hernia and was lying behind the right mesocolon. No bowel ischemia	Discharged on POD 10. No readmission. Last follow-up in 2023
26/F	Left PDH	3 years	Preoperative	Clumped-up bowel loops in left anterior pararenal space behind IMV	CIO	Laparoscopic repair (2022): Lenzert’s defect identified with small bowel loops about 10 cm distal to DJ flexure as content. No bowel ischemia/malrotation	Discharged on POD 3. Readmitted on POD 7 with recurrent vomiting, no recurrence found. Last follow-up in 2023
36/M	Left PDH	11 months	Preoperative	Clumped-up bowel loops in left anterior pararenal space behind IMV and ascending left colic artery with mesenteric fat stranding and oedema	CIO	Laparoscopic repair (2023): Lenzert’s defect identified with small bowel loops about 20 cm distal to DJ flexure as content. No bowel ischemia/ malrotation	Discharged on POD 5. No recurrence. Last follow-up in 2023
Acquired internal hernia
31/F	Trans-mesenteric via JJ site (post lateral pancreaticojejunostomy)	1 year	Preoperative	Mesenteric whirling	CIO	Open repair (2012): Omental/parietal adhesions. Distal jejunum and proximal ileum herniated through the JJ site mesenteric window. Small defect also noted in the mesocolic window of the Roux loop. No bowel ischemia	No recurrence of IH. However, required admission in view of primary disease (pain and brittle diabetes related to cervical chest pain). Last follow-up in 2022
64/M	Trans-mesenteric via mesocolon anterior to GJ site (post RYGJ)	1 year	Preoperative	Mesenteric whirling and clumping of bowel loops near GJ site	CIO	Open repair (2014): Mild free fluid in the peritoneal cavity. A 5 × 5 cm defect in the mesocolon anterior to GJ. No bowel ischemia	Required readmission 1 month postoperatively in view of melena. Developed hypoglycaemic seizures during the hospital admission. Was managed conservatively and discharged. Subsequently lost to follow-up
22/M	Trans-mesenteric via previous ileoileostomy site (post TPC with IPAA)	4 days	Intraoperative	None	AIO	Open repair (2021): Dense omental and interbowel adhesions present. One litre of serohemorrhagic fluid present. Small bowel loops herniated through mesenteric window of previous ileo-ileal anastomotic site-gangrenous. 1.5 feet gangrenous ileal segment resected. End ileostomy fashioned 8 feet distal to DJ site in right lower quadrant and distal mucus fistula in lower end of midline	Elective admission for restoration of bowel continuity 3 months later. Subsequently no readmission. No recurrence. Last follow-up in 2023

F: Female; M: Male; PDH: Paraduodenal hernia; AIO: Acute intestinal obstruction; POD: Post-operative day; CIO: Chronic intestinal obstruction; IMV: Inferior mesenteric vein; RYGJ: Roux en Y gastrojejunostomy; TPC with IPAA: Total proctocolectomy with ileal pouch anal anastomosis; JJ: Jejunostomy.

Table 2 Comparison of results of various studies available in the literature

Ref.	Number of patients with IH	Presentation	Preoperative diagnosis	Type of surgery (laparoscopic/open)	Outcome
Newsom et al [25], (1986)	14 [CIH (n = 8), AIH (n = 6)]	AIO (n = 14), CIO (n = none)	None (based on roentgenogram)	All open; operated as emergency surgery; 9 required bowel resection	Postoperative mortality: 31%
Ghiassi et al[26], (2007)	49 [CIH (n = 15), AIH (n = 34)]	AIO (n = 37), CIO (n = 11)	4 (based on computed tomography scan)	Open (n = 31); laproscopy (n = 13); laproscopy converted to open (n = 5). All operated as emergency surgery; 11 required bowel resections	Postoperative mortality: 2%. Morbidity: 12%
Poves et al[27], (2014)	6 [CIH (n = 2), AIH (n = 4)]	AIO (n = 6), CIO (n = none)	NA	Laproscopy (n = 4), laproscopy converted to open (n = 2). All 6 operated as emergency surgery; 2 required bowel resections	NA
John et al[28], (2016)	6 [CIH (n = 4), AIH (n = 2)]	AIO (n = 6), CIO (n = none)	1	All open; operated as emergency surgery; 3 required bowel resections	Postoperative mortality: None. Morbidity: NA
Present Study	7 [CIH (n = 4), AIH (n = 3)]	AIO (n = 2), CIO (n = 5)	5	Open (n = 3), laproscopy (n = 4). The 2 operated as emergency and 5 as semi-elective surgery; 1 required bowel resection	Postoperative mortality: None. Morbidity: 14%

IH: Internal hernia; CIH: Congenital internal hernia; AIH: Acquired internal hernia; AIO: Acute intestinal obstruction; CIO: Chronic intestinal obstruction; Open: Laparotomy; Laproscopy: Laparoscopic surgery.