Nair H S, Watt K A, Anderson D N
Lothian Colorectal Surgery Unit, Western General Hospital, Crewe Road South, Edinburgh, Scotland, UK.
Lothian Colorectal Surgery Unit, Western General Hospital, Crewe Road South, Edinburgh, Scotland, UK.
Int J Surg Case Rep. 2015;11:68-70. doi: 10.1016/j.ijscr.2015.01.051. Epub 2015 Feb 26.
Internal herniae, although rare, can give rise to potentially serious morbidity and mortality. The protrusion and entrapment of the small bowel through an embryological or iatrogenic mesenteric aperture within the confines of the peritoneal cavity can be difficult to diagnose, and delay treatment (operative). Timely intervention must be achieved to minimize small bowel ischemia and infarction.
In this case, a young lady who had a previous laparoscopic total colectomy and ileostomy developed an unusual internal hernia. Small bowel was passing behind the lesser curvature of the stomach causing the stomach to be rotated to form of a tight "band" trapping bowel. The herniated small bowel was reduced, hence, avoiding resection; the defect closed by interupted 4-0 PDS. "Prompt" surgery avoided small bowel length resection and sacrifice of the ileoanal pouch reconstruction.
It is theorized that a laparoscopic approach results in a more advanced mobilization of the mesentery right up to the small bowel origin, and with less adhesion formation may in fact promote unusual internal hernia and volvulus.
The case presented highlights the difficulty in making the diagnosis, and the pictures clearly indicate an unusual hernia passing directly behind the stomach and involving a large section of the small bowel. The lead up history of several admissions with sub acute small bowel obstruction suggested the underlying problem was adhesional but quite clearly there was a well defined internal hernia. Without timely surgery she would have been at high risk of losing her pouch.
内疝虽然罕见，但可能导致严重的发病和死亡。小肠通过腹膜腔内胚胎学或医源性肠系膜孔的突出和嵌顿可能难以诊断，并延误治疗（手术）。必须及时进行干预，以尽量减少小肠缺血和梗死。
在本病例中，一名曾接受腹腔镜全结肠切除术和回肠造口术的年轻女性发生了一种不寻常的内疝。小肠从胃小弯后方通过，导致胃旋转形成一个紧绷的“束带”，困住肠管。突出的小肠得以复位，从而避免了切除；缺损用4-0可吸收聚对二氧环己酮间断缝合关闭。“及时”的手术避免了小肠段切除和回肠肛管储袋重建的牺牲。
理论上，腹腔镜手术会导致肠系膜直至小肠起始部的更广泛游离，且粘连形成较少，实际上可能会促进不寻常的内疝和肠扭转。
所呈现的病例突出了诊断的困难，图片清楚地显示了一个直接在胃后方通过且累及大部分小肠的不寻常疝。多次因亚急性小肠梗阻入院的病史提示潜在问题是粘连，但很明显存在一个明确的内疝。如果不及时手术，她失去储袋的风险会很高。
