0:01

All right.

0:02

Let's preview cases 15 through 18.

0:06

Okay.

0:10

Here's your 25 year old with abdominal pain.

0:14

Normal.

0:16

Usually it's taking longer because

0:17

usually I talk with everyone forever.

0:19

Anyway, so here we see a bunch of small

0:21

bowel here on the, in the left abdomen.

0:24

Let's go down.

0:26

Now we're going to look at my favorite

0:28

vein, which I already told you was the IMV.

0:31

The IMV here drains into the portal vein.

0:32

In this case, it's kind of variable

0:34

between the splenic or SMD.

0:36

Pardon me.

0:37

And then we're going to come down that IMV is coming

0:40

very anterior, not in the location we saw previously.

0:45

It's normal location is right anterior to the

0:47

renal vein, but this IMV is pushed forward.

0:52

We're coming down, we're coming down, and

0:55

then it's going to dive back down deep into

0:59

the pelvis where it wants to be, right?

1:02

And it's going to go to.

1:04

the sigmoid colon.

1:09

All right.

1:09

So this is anterior displacement of

1:11

the IMV by this lump of small bowel.

1:17

Anyone?

1:19

Yay.

1:20

All right.

1:21

So this is a classic appearance

1:23

of a left peritoneal hernia.

1:26

All right.

1:26

The left peritoneal hernia, it's not that common.

1:29

Um, it is a result of a, um, congenital

1:36

incomplete fusion resulting in an abnormal

1:39

fossa of Walden, Walden Dyer here.

1:42

Um, and as a result, the small bowel is

1:45

able to herniate through this incomplete

1:47

fusion in the descending colonic mesentery.

1:49

Um, it's kind of a congenital

1:51

orifice and result in a hernia.

1:54

Frequently, they aren't actually obstructed.

1:56

Frequently, they're kind of like this.

1:57

There's a bunch of like, uh, small

1:59

bowel loops bunched together.

2:01

And if you're trying to make this diagnosis, um,

2:04

you want to use the IMV as your landmark of where,

2:08

um, the bowel is, and that's where it's herniated

2:11

through that retroperitoneal fossa of Lanzard.

2:14

I'm sorry, did I say.

2:15

Wallendeyer, that's on the right, Fossa of Lanzert.

2:19

Again, DWG, I kind of forgot all their names.

2:22

In this case, the internal

2:25

hernias can be of various types.

2:27

They can either go through a mesenteric

2:28

foramen, um, and, uh, uh, extend through

2:31

the whole orifice, or they can actually come

2:33

through in an intramesenteric pouch type.

2:36

And this is the type we have, is this

2:37

kind of pouch type, where it's still, um,

2:40

uh, surrounded by one layer of mesentery.

2:44

So that's a left peritoneal to a duodenal hernia.

2:47

Now, I don't have a right peritoneal duodenal hernia.

2:50

So I borrow this with permission and, um,

2:53

and complete love, um, from Radiopaedia.

2:56

I don't have this case because it's really,

2:58

really uncommon, but I've always wanted one.

3:00

So if you get one, you have to send it to me.

3:02

And as you come down here, you're going to see a kind

3:06

of similar appearance, that, um, saran wrap look of

3:09

a, of, uh, of a grouping of small bowel on the right.

3:13

And in this case, it's actually

3:15

coming posterior to the SMV.

3:18

This is a right paroduodenal hernia.

3:20

These are much less common.

3:22

I mean, of an uncommon entity, these are

3:24

actually even less common, um, mostly because

3:29

You usually have to have some degree of small

3:31

bowel mal rotation, even for this to occur,

3:33

for it to herniate posterior to that SMV, SMA.

3:37

Um, but again, that appearance of like a, of

3:39

a grouping of bowel kind of smooshed together,

3:42

um, because of that extension through the one

3:44

layer of the peritoneum is really important.

3:47

So that is, um, a right paroduodenal hernia.

3:52

And if you Okay, here is case

3:56

16, sudden onset abdominal pain.

4:00

normal.

4:02

I'm just going to let this play twice

4:04

because we have a little bit of time.

4:05

I don't want to like waste your time or

4:06

anything, but you might want to see it twice.

4:15

All right, let's go through the coronals in this case.

4:19

Here's the liver, and we're going to

4:22

notice that this is the stomach over here.

4:25

And here's a big pouch of air filled GI tract.

4:29

Okay.

4:30

And when we come, we can actually see that

4:32

it's pulling up this small bowel loop as well.

4:41

So this is actually extending

4:44

posterior to the portal vein.

4:46

Don't worry, we'll see that in a moment.

4:49

And it is the cecum and the terminal ileum being

4:53

pulled up here into the right upper quadrant,

4:56

posterior to the portal vein, anterior to the IVC.

5:05

Anyone want to make a guess?

5:09

So I had two of these in one month.

5:11

I was so excited.

5:12

Stomach.

5:14

This is the cecum with a small bowel

5:16

between the portal vein and the IVC.

5:19

This is a Winslow hernia.

5:23

So this is through the, um, foramen of Winslow.

5:26

Uh, you may remember that as the foramen that

5:28

gets you to the lesser sac behind the stomach.

5:31

Um, It's a very infrequent internal hernia.

5:35

Again, the two I've seen in the

5:36

last year were both the cecum.

5:39

I mean, the number of variabilities that have to occur

5:42

for you to have an immobile cecum that then goes up and

5:45

herniates through that foramen is pretty impressive.

5:48

But classically, the key is to see it

5:50

between the portal vein and the IVC.

5:54

Um, this is a sagittal image, uh, where you can see

5:57

the, um, lesser sac posterior to the stomach here,

6:00

kind of outlined with this nice blue, uh, blue writing.

6:03

This is the foramen of Winslow, it's very

6:05

small in this location, um, and you can see

6:08

here that it's liver with that dilated loop

6:11

of, uh, cecum here and the stomach below.

6:14

So this is cecum going into that lesser sac.

6:16

So that is a, um, foramen of Winslow hernia.

6:27

Oh, what?

6:28

So this is a question of what imaging science

6:30

do I look for for ischemia of the small bowel?

6:32

You know, we usually talk about high grade

6:34

being the degree of mesenteric edema,

6:36

ascites, and, uh, differential enhancement.

6:39

So I think if I see a lot of ascites or mesenteric

6:42

edema, I will say that it's a high grade

6:44

obstruction, possibly, uh, ischemic in nature.

6:47

And those usually go to surgery because they

6:48

just can't be treated, um, conservatively.

6:51

Usually the patients are, have too

6:52

high of a lactate or are unstable.

6:55

So those are usually going to go to surgery.

6:57

I hope that answers that question.

6:59

Um, but frequently I'm telling you the

7:01

best thing I look for, for small bowel

7:03

obstructions is the degree of ascites.

7:05

And.

7:06

mesenteric edema.

7:08

Um, okay.

7:11

We only have two more cases, but if I were going

7:13

to do internal hernias and leave out gastric

7:17

bypass hernias, that would be a big miss.

7:19

Um, In general, there aren't that many

7:22

internal hernias in the world, right?

7:24

Um, there are all these kind of congenital

7:27

fossas, um, as I told you, Lanzer, Waldeyer, um,

7:32

all that, which are, you know, Winslow, which

7:34

are all possible locations for internal hernias.

7:36

There's also some funny mesenteric, um, uh, rents in

7:41

the mesentery, frequently from trauma, past trauma can

7:44

occur, um, and those can allow for internal hernias.

7:47

some weird broad ligament hernias because of prior

7:50

GYN surgeries and the like, but nothing brings

7:53

you internal hernias as much as gastric bypass.

7:58

So when you're doing a gastric bypass, you are making

8:01

a small little gastric pouch and you're bringing a

8:03

small, a digenital loop up to that gastric pouch.

8:05

Now your choices are to go anterior to the

8:08

colon, Sorry, with my background, you can't

8:10

see my hand or go posterior to the colon

8:12

through the meso colon at Mass General.

8:15

Our surgeons choose to go through the meso colon.

8:18

They think it's a more, um, successful gastric bypass.

8:21

And they believe it's more anatomic for drainage

8:25

patients don't have as much as many consequences.

8:29

So we always have a retro colonic gastric bypass.

8:32

Um, and, uh, so.

8:36

Here we are.

8:36

We have a 36 year old with abdominal

8:38

pain history of gastric bypass.

8:39

You can see this little gastric patch here.

8:41

There are a number of very dilated loops of

8:44

small bowel here in the left upper quadrant.

8:48

Now we're going to go through on the coronals

8:51

because I think the coronal view is much nicer.

8:53

Um, and you're going to see these loops of

8:56

small bowel up into the left upper quadrant.

8:58

They're dilated.

8:59

They're obstructed.

9:00

Let's be clear.

9:03

Let me pause that.

9:07

Again, dilated, obstructed lips, a small bowel.

9:10

And on the coronal image here, you can see that these

9:13

mesenteric vessels are, um, there's traction and

9:16

they're torsed on up into the left upper quadrant.

9:19

This is Wait for it.

9:23

Um, an internal hernia through the mesocolonic window.

9:26

Again, I was saying that in order to get

9:28

your jejunal loop to the stomach, you have

9:30

to go through the transverse mesocolon.

9:33

So you need to make a little laceration

9:34

there in that transverse mesocolon.

9:36

You bring up your roux limb, um, And

9:39

you sew it to your gastric patch.

9:40

Now, whenever you're bifurcating mesentery and

9:43

sewing things in different places, you're definitely,

9:45

um, allowing the possibility for internal hernias.

9:49

This specific internal hernia through the mesocolon

9:51

tends to occur as a delayed gastric bypass.

9:54

Uh, complication because, um, just like you lose weight

10:00

in all parts of your body when you have a gastric

10:02

bypass, you also actually lose it from the mesentery.

10:05

So as you lose weight from the mesentery and lose

10:07

fat from the mesentery, this hole can get bigger.

10:09

Also, As, um, you lose weight, like every ligament

10:13

is structure in your abdomen, the hell your bowel

10:15

loops now has kind of like recoiled a little bit.

10:18

It's become a little more floppy.

10:19

So it's just really easy for small bowel

10:21

loops of somebody who has had significant

10:23

weight loss, um, to Taurus and the like.

10:26

So it's kind of one of the

10:27

complications usually delayed from.

10:30

Um, this surgery.

10:32

So this is a beautiful

10:33

transmedia, colic window, hernia.

10:35

Frequently those bowel loops will be in the

10:37

left upper quadrant and they will be obstructed.

10:39

Um, and that is a pretty hernia, but

10:41

I wanted to bring you another one.

10:42

There are two other possibilities.

10:44

There is the, um, let me, I have a bigger look at this.

10:48

Um, here's a transmedia colic

10:49

hernia defect that we just saw.

10:51

There's the retro limb, um, Peterson's hernia.

10:54

This is a really common hernia.

10:56

Um, I see it.

10:58

probably almost every month, uh, and it is a

11:01

hernia through the, um, posterior, uh, roux

11:05

limb because there's now a, uh, a foramen

11:09

when that mesentery is brought upwards.

11:11

You can also get a retro small bowel,

11:13

um, hernia from the jejunal anastomosis.

11:16

I think I've only seen that once or twice.

11:17

So this Peterson hernia is one to really look out for.

11:20

Let's look here.

11:22

Here's a patient who's status post gastric bypass.

11:25

Let's look here.

11:26

Oh, sorry.

11:28

Let's move downward.

11:29

I'm sorry.

11:30

This is jumping.

11:31

Now, let's do a shock and awe, and I'll come back up.

11:36

I'm going to go all the way down,

11:40

then we're going to go back up.

11:43

Normal.

11:47

Okay.

11:48

So, notice, this patient has had a gastric bypass.

11:51

I don't know why I didn't show you the

11:52

image of the actual gastric bypass.

11:53

I think this is the, uh, movie file.

11:56

There we go.

11:56

That's going to show it.

11:58

Um, and as you come down, you're going to see

12:00

a nice little gastric bypass, gastric pass,

12:02

jejunal loop, nicely contrast, opacified.

12:05

We use very little contrast in the ER anymore, but

12:08

I do kind of like it in the gastric bypass patients.

12:10

I have to tell you, no, this is not obstructed.

12:12

There's small bowel contrast material going

12:15

throughout the whole small bowel without

12:16

obstruction, but this is by no means normal.

12:20

So as we come down, we're going to notice

12:23

that the ligament of trite has moved

12:27

to the leftward aspect of the abdomen.

12:29

This is one of the findings that is

12:30

significant in this kind of hernia.

12:34

When we're coming down here, you're going to

12:35

notice the whole mesentery is very gray as

12:38

opposed to the normal subcutaneous fat here.

12:40

Very gray.

12:42

Also, these are big.

12:45

Are they lymph nodes?

12:46

No, those are portal veins.

12:48

They're very, very dilated.

12:50

Um, not really enhancing, but very dilated.

12:51

And you also have normal size arteries.

12:54

So we have a lot of mesenteric edema,

12:57

and I've seen people, here's a coronal.

13:05

I've seen people want to call this portal vein

13:07

thrombosis, and I've seen it come to our hospital

13:09

misdiagnosis that on numerous occasions, because when

13:13

you look at the portal vein, you don't see it well.

13:15

Okay.

13:16

Um, it's basically cut off.

13:18

That is going to be one of the findings.

13:20

And one of the first things I look at on every

13:22

gastric bypass is I bring it on coronal and

13:25

I look at that SMV and I see if it's vertical

13:28

and I can see that that whole SMV is enhancing.

13:31

I'm already drinking coffee and relaxing.

13:33

Okay.

13:34

But.

13:34

If I don't see that, then I'm really

13:36

concerned about a Peterson hernia.

13:38

So here we already have, um, the loss of the SMV gone.

13:44

Another finding.

13:44

So we already had the ligament of

13:46

trite going to the left abdomen.

13:47

We've lost the SMV.

13:49

And now the next finding we're going to

13:50

also look at is to find the terminal ileum.

13:54

That is going to be outlined

13:56

here with the green arrows.

13:57

You're going to look for the terminal ileum.

13:59

That terminal ileum is going to go all the way across

14:02

the abdomen and then to the left upper quadrant.

14:04

Um, this is such a dramatic hernia that when

14:07

I've talked to the surgeons, um, all of the

14:11

small bowel is through that orifice, okay?

14:14

It doesn't obstruct, it's just that it torces

14:17

deep and results in ischemia because it torces

14:21

deep and it causes the portal vein to be cut

14:23

off from that torsion into that deep hernia.

14:26

As a result, you'll get this mesenteric edema,

14:29

frequently no bowel obstruction, and you'll get this

14:32

abnormal configuration of the bowel, which includes,

14:36

right, where deviation of the ligament of trites.

14:39

loss of FSMV and the, the terminally being twist

14:43

up or tethered up into the left upper quadrant.

14:46

Um, this is a Peterson hernia.

14:48

They all look exactly the same.

14:49

I could show you 15, 20 of them on my, on my computer.

14:52

Um, but definitely know this hernia.

14:55

If you have a population of patients who've had

14:57

gastric bypasses, you will see it again and again.

15:01

And again, it's a deep hernia, so it

15:04

really, um, has all the bowel through there.

15:07

And the surgeons say that they just have to, like,

15:08

yank it out slowly, um, because it's so very dramatic.

15:14

Well, I hope that was helpful.

15:16

That was 18 cases of hernias

15:19

and small bowel obstructions.

15:21

Um, remember, time is battle, so we want

15:23

to always move fast when we're diagnosing

15:25

small bowel obstructions, um, and the like.

15:28

Uh, if there's any questions, I

15:29

would be happy to answer them.

15:32

I know I'm a little bit fast here today.

15:34

About 10 minutes, which, you know, no one

15:36

ever argues that you're over quickly, right?

15:38

And I'm sure if you do this in a delayed

15:40

fashion, you'll have a lot of time

15:42

to look at those cases beforehand.

15:44

So that may be of use, but I thank

15:46

you very much for your attention.

15:49

And I hope that this was helpful.