Image of the Month—Diagnosis | Surgery | JAMA Surgery | JAMA Network
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Special Feature
October 19, 2009

Image of the Month—Diagnosis

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

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