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October 19, 2009

Image of the Month—Diagnosis

Arch Surg. 2009;144(10):975-976. doi:10.1001/archsurg.2009.171-b

Answer: Incarcerated Paracecal Hernia

As we approached the end of the small bowel, we encountered a loop of terminal ileum incarcerated in a defect in the cecal mesentery. Gentle traction was applied with atraumatic forceps, which successfully released the incarcerated bowel. The mesentery around the defect was opened widely, thereby obliterating the natural orifice. The terminal ileum was then closely inspected and found to be viable. The patient tolerated the procedure. His postoperative course was uncomplicated, aside from a postoperative ileus that delayed the advancement of his diet. He was discharged on postoperative day 6 feeling well and tolerating a regular diet.

An internal hernia is defined as protrusion of a viscus through a peritoneal or mesenteric aperture. They are a rare cause of intestinal obstruction that make up fewer than 6% of all cases.1,2The aperture involved may be congenital, acquired secondary to surgery or trauma, or a preexisting anatomic structure such as the foramen of Winslow.3Naturally occurring internal hernias can be divided into 6 basic categories: transmesenteric, paraduodenal, transomental, paracecal, intersigmoid, paravesical/pelvic, and hernias through the foramen of Winslow.4Paracecal hernias are responsible for only 1.0% to 6.6% of internal hernias.5,6The anatomy of the cecal and paracecal peritoneum is the end result of ileocecal migration that occurs during rotation of the midgut in the fifth month of gestation. At that stage, 4 distinct peritoneal recesses of various depths occur in the paracecal area, namely the superior and inferior ileocecal recess, retrocecal recess, and paracolic sulci, all of which may become hernial orificies.7,8

Internal hernias are very difficult to diagnose preoperatively owing to the lack of specific signs and symptoms or characteristic findings on plain films or computed tomographic scans. In our case, computed tomography was able to confirm our suspicion of small-bowel obstruction but could not clearly identify the etiology. Definitive diagnosis usually requires direct visualization of the hernia either by diagnostic laparoscopy or open surgery. As surgeons become increasingly comfortable with more advanced laparoscopic techniques, more of these cases will be able to be definitively treated laparoscopically as well. Nevertheless, whether the approach be open or laparoscopic, this case serves to reinforce the dictum that small bowel obstruction in a patient with a “virgin abdomen” is a surgical disease and requires early operative intervention.

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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system ( Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery ( No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

Correspondence:Avraham Schlager, MD, Department of General Surgery, New York University Hospital, 137-23 76th Ave, Flushing, NY 11367 (

Accepted for Publication:January 2, 2009.

Author Contributions:Study concept and design: Khalaileh, Schlager, Abu-Gazalah, and Rivkind. Acquisition of data: Khalaileh, Adileh, and Keidar. Analysis and interpretation of data: Mintz. Drafting of the manuscript: Khalaileh, Adileh, Abu-Gazalah, and Keidar. Critical revision of the manuscript for important intellectual content: Schlager, Mintz, and Rivkind. Administrative, technical, and material support: Schlager and Mintz. Study supervision: Rivkind and Keidar.

Financial Disclosure:None reported.

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