Martin et al.

Gastrointestinal Imaging • Review

Radiographic and Clinical
Findings of Hernias

A C E N T U
R Y O F

Review of Internal Hernias:

MEDICAL IMAGING
Radiographic and Clinical Findings
Lucie C. Martin1 OBJECTIVE. Internal hernias, including paraduodenal (traditionally the most common),
Elmar M. Merkle pericecal, foramen of Winslow, and intersigmoid hernias, account for approximately 0.5–5.8%
William M. Thompson of all cases of intestinal obstruction and are associated with a high mortality rate, exceeding
50% in some series. To complicate matters, the incidence of internal hernias is increasing be-
Martin LC, Merkle EM, Thompson WM cause of a number of relatively new surgical procedures now being performed, including liver
transplantation and gastric bypass surgery. A significant increase in hernias is occurring in pa-
tients undergoing transmesenteric, transmesocolic, and retroanastomotic surgical procedures.
It is important for radiologists to be familiar with and to understand the various types of internal
hernias and their imaging features so that prompt and accurate diagnosis of these conditions
can be made.
CONCLUSION. This article illustrates the imaging findings of internal hernias, with em-
phasis placed on the CT findings, especially in transmesenteric, transmesocolic, and retroanas-
tomotic types of internal hernias.

A
lthough internal hernias have an of intestinal loops through a defect in the wall
overall incidence of less than of the abdomen or pelvis, and internal hernias
1%, they constitute up to 5.8% of are defined by the protrusion of a viscus
all small-bowel obstructions, through a normal or abnormal peritoneal or
which, if left untreated, have been reported mesenteric aperture within the confines of the
to have an overall mortality exceeding 50% peritoneal cavity. The orifice can be either ac-
if strangulation is present [1, 2]. Over the quired, such as a postsurgical, traumatic, or
past decade, their incidence has been in- postinflammatory defect, or congenital, in-
creasing because of the more frequent per- cluding both normal apertures, such as the fo-
formance of liver transplantations and gas- ramen of Winslow, and abnormal apertures
tric bypass surgery for bariatric treatment. arising from anomalies of internal rotation
In this subset of patients, internal hernias and peritoneal attachment.
account for just over half of all cases of In the broad category of internal hernias
small-bowel obstruction, almost equal to are several main types, as traditionally de-
those caused by adhesions in one study [3, scribed by Meyers [5], based on location.
4]. Without a heightened awareness and un- Specifically, using historical data, these
Keywords: colon, CT, gastrointestinal radiology, hernia, derstanding of these hernias, they can often consist of paraduodenal (53%), pericecal
small bowel
be misdiagnosed, with subsequent signifi- (13%), foramen of Winslow (8%), trans-
DOI:10.2214/AJR.05.0644 cant morbidity and mortality. The purpose mesenteric and transmesocolic (8%), inter-
of this article is therefore not only to review sigmoid (6%), and retroanastomotic (5%)
Received April 14, 2005; accepted after revision the definition and types of internal hernias, (Fig. 1), with the overall incidence of inter-
August 9, 2005.
but also to describe the clinical and radio- nal hernias being 0.2–0.9%. The other 7%
1All authors:
Department of Radiology, Duke University
graphic findings, with an emphasis placed described by Meyers included paravesical
Medical Center, Box 3808, Durham, NC 27710. Address on the CT features, because CT is rapidly hernias, which are not true internal hernias
correspondence to W. M. Thompson becoming the first-line imaging technique and thus are not described in this article. In
([email protected]). in these patients. general, internal hernias have no age or sex
AJR 2006; 186:703–717
predilection. With more new surgical proce-
Definition dures being performed using a Roux loop,
0361–803X/06/1863–703
Hernias are of two main types, external and the number of transmesenteric, transmeso-
© American Roentgen Ray Society internal [1]. External hernias refer to prolapse colic, and retroanastomotic internal hernias

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 Martin et al.

Fig. 1—Diagrammatic commonly in men by a ratio of 3:1 [1, 2, 6].

illustration shows There are two main types, left and right,
various types of internal
hernias: with the former consisting of most (75%)
A = paraduodenal, cases [1, 6–8].
B = foramen of Winslow,
C = intersigmoid,
D = pericecal,
Left Paraduodenal Hernia
E = transmesenteric, and Left paraduodenal hernias have an overall
F = retroanastomotic. incidence of approximately 40% of all inter-
nal hernias. They occur when bowel pro-
lapses through Landzert’s fossa, an aperture
present in approximately 2% of the popula-
tion (Fig. 1). These hernias therefore can be
classified as a congenital type, normal aper-
ture subtype. Landzert’s fossa is located be-
hind the ascending or fourth part of the
duodenum and is formed by the lifting up of
a peritoneal fold by the inferior mesenteric
vein and ascending left colic artery as they
run along the lateral side of the fossa. Small-
bowel loops prolapse posteroinferiorly
through the fossa to the left of the fourth
part of the duodenum into the left portion of
the transverse mesocolon and descending
mesocolon (Fig. 2).
Clinically, in addition to the aforemen-
tioned symptomatology, these patients will
also often present with postprandial pain, typ-
ically chronic in nature, with symptoms dat-
ing back to childhood [5].
On radiography or oral contrast studies,
has been increasing. These are probably cally. In the past, these hernias were most fre- these hernias will present as an encapsulated
more common than the traditional incidence quently assessed with small-bowel oral circumscribed mass of a few loops of small
of the various types of internal hernias re- contrast studies. However, CT has become the bowel (usually jejunal) in the left upper
ported by Meyers (Table 1). first-line imaging technique in these patients quadrant, lateral to the ascending duodenum
because of its availability, speed, and multi- [1, 5, 9] (Fig. 3A). These loops may have
General Clinical Findings planar reformatting capabilities. General ra- mass effect, depressing the distal transverse
Clinically, internal hernias can be asymp- diographic features with barium studies in- colon and indenting the posterior wall of the
tomatic or cause significant discomfort clude apparent encapsulation of distended stomach [1, 5] (Figs. 3B and 3C). Mild
ranging from constant vague epigastric pain bowel loops with an abnormal location, ar- duodenal dilatation often occurs, and the ef-
to intermittent colicky periumbilical pain rangement or crowding of small-bowel loops ferent loop often shows an abrupt caliber
[1, 5] (Table 1). Additional symptoms in- within the hernial sac, evidence of obstruction change [5]. With CT, similar findings of en-
clude nausea, vomiting (especially after a with segmental dilatation and stasis, with ad- capsulated bowel loops are noted, either at
large meal), and recurrent intestinal ob- ditional features of apparent fixation and re- the duodenojejunal junction between the
struction [1, 2, 5–7]. Symptom severity re- versed peristalsis during fluoroscopic evalua- stomach and pancreas to the left of the liga-
lates to the duration and reducibility of the tion [1, 5] (Table 1). On CT, additional ment of Treitz; behind the pancreatic tail it-
hernia and the presence or absence of incar- findings include mesenteric vessel abnormal- self, displacing the inferior mesenteric vein
ceration and strangulation [6]. These symp- ities, with engorgement, crowding, twisting, to the left; or between the transverse colon
toms may be altered or relieved by changes and stretching of these vessels commonly and the left adrenal gland [5–7, 9–12]
in patient position [5, 7]. Because of the pro- found and providing an important clue to the (Figs. 4A–4D). Evidence of small-bowel ob-
pensity of these hernias to spontaneously re- underlying diagnosis [6]. struction with dilated loops and air–fluid
duce, patients are best imaged when they are levels is also commonly seen [5] (Fig. 4E).
symptomatic [5, 7]. Paraduodenal Hernias There is associated mass effect with dis-
In the classic older literature, paraduode- placement of the posterior stomach wall an-
General Imaging Findings on nal hernias were the most common type of teriorly, the duodenojejunal junction infero-
Radiography and CT internal hernia, accounting for approxi- medially, and the transverse colon inferiorly
Imaging studies often play an important mately 53% of all cases [1]. Unlike most [6, 7, 10]. Mesenteric vessel abnormalities,
role in the diagnosis of internal hernias be- types of internal hernias, this subtype does including enlargement, stretching, and ante-
cause they are often difficult to identify clini- have a sex predilection, being found more rior displacement of the main mesenteric

704 AJR:186, March 2006

 TABLE 1: Clinical and Imaging Findings for Internal Hernias
AJR:186, March 2006

Characteristic Radiography and Barium

Hernia Type Subtype Incidencea Clinical Findings Studies CT Findings Key Vessel

Left paraduodenal Congenital, normal 40% of all hernias, Postprandial pain, may date Encapsulated cluster of Clustered dilated small-bowel IMV in neck of hernial sac with
aperture 75% of back to childhood jejunum in LUQ, lateral to the loops between stomach and anterior and upward
paraduodenal ascending duodenum; may pancreas, behind pancreas displacement of IMV
hernias have mass effect indenting itself, or between transverse
posterior wall of stomach or colon and left adrenal gland
displacing transverse colon
inferiorly
Right paraduodenal Congenital, normal 13% of all hernias, Postprandial pain, may date Encapsulated loops lateral Encapsulated loops lateral SMA displaced anteriorly
aperture 25% of back to childhood and inferior to the and inferior to the
paraduodenal descending duodenum; descending duodenum;
hernias associated with small-bowel associated with small-bowel
nonrotation nonrotation

Pericecal Congenital or acquired, 13% RLQ pain, differential Clustered small-bowel loops Clustered small-bowel loops None

Radiographic and Clinical Findings of Hernias

abnormal aperture diagnosis of appendicitis; (usually distal) posterior and (usually distal) posterior and
high incidence of occlusive lateral to the cecum in right lateral to the cecum in right
symptoms paracolic gutter paracolic gutter

Foramen of Winslow Congenital, normal 8% Symptoms of proximal Circumscribed loops medial Loops in lesser sac between None; vessels stretched
aperture obstruction because of mass and posterior to the stomach; liver hilum and IVC through foramen of Winslow
effect on stomach; symptom differential diagnosis of cecal
onset often preceded by volvulus
changes in intraabdominal
pressure (i.e., parturition,
straining); relief of symptoms
with forward bending
Intersigmoid Type 1: congenital, 6% None U- or C-shaped cluster of U- or C-shaped cluster of None
normal aperture; types 2 small bowel posterior and small bowel posterior and
and 3: acquired, lateral to the sigmoid colon lateral to the sigmoid colon
abnormal aperture
Transmesentericb In children: congenital, 8% Two typical patient Variable, air within gastric Small bowel lateral to colon; None
abnormal aperture; in populations: children and remnant; may simulate a left displaced omental fat with
adults: usually acquired, postsurgical adults; in adults, paraduodenal hernia small bowel directly abutting
abnormal aperture less vomiting because fewer abdominal wall
secretions in proximal gastric
pouch, onset more acute

Retroanastomoticb Acquired, abnormal 5% Usually within the first Variable Variable None
aperture postoperative month; less
vomiting because fewer
secretions in the proximal
gastric pouch
Note—LUQ = left upper quadrant, IMV = inferior mesenteric vein, SMA = superior mesenteric artery, RLQ = right lower quadrant, IVC = inferior vena cava.
a Incidence for first six types from Meyers [5], which are historic data but only major source currently available. Incidence for these first six types of internal hernias totals only 93% because perivesical hernias reported
[5] are not true internal hernias, so they were not included in this review.
b Probably more transmesenteric and retroanastomotic internal hernias currently because of number of liver transplant and gastric bypass operations being performed throughout the United States during past decade.
The 5% refers to the incidence after Roux loops used during surgery for reasons other than liver transplantation or gastric bypass.
705
 Martin et al.

Fig. 2—Graphic be congenital, related to abnormalities of

illustration of a left embryologic midgut rotation, there may be
paraduodenal hernia
depicts loop of small additional clues such as small-bowel nonro-
bowel prolapsing tation, as evidenced by the superior mesen-
(curved arrow) through teric vein occupying a more ventral and left-
Landzert’s fossa, located
behind inferior
ward position and the absence of a normal
mesenteric vein and horizontal duodenum [5, 8, 9]. The cecum,
ascending left colic however, remains in its normal position.
artery (straight arrow). Vascular findings include jejunal branches
Herniated bowel loops
are therefore located of the superior mesenteric artery and supe-
lateral to fourth portion of rior mesenteric vein looping posteriorly and
duodenum. to the right of the parent vessel to supply the
herniated loops [1, 5, 8, 9]. Additional vas-
cular findings include the presence of the
superior mesenteric artery, ileocolic artery,
and right colic vein in the anterior margin of
the neck of the hernial sac, displaced anteri-
orly if there is sufficient mass effect by the
encased small-bowel loops [8]. Again, ves-
sel engorgement may also be present and
provide a clue to the diagnosis.

Pericecal Hernias
Historically, pericecal hernias account for
13% of all internal hernias. The pericecal fossa
is located behind the cecum and ascending co-
lon and is limited by the parietocecal fold out-
ward and the mesentericocecal fold inward [9].
Although there are actually four subtypes (ile-
trunks, especially the inferior mesenteric half of the transverse mesocolon and behind ocolic, retrocecal, ileocecal, and paracecal) of
vein, to the left, are also helpful findings [10, the ascending mesocolon. This type of her- pericecal hernias, most commonly the herni-
11]. If the vasculature is optimally visual- nia occurs more frequently in the setting of ated loop consists of an ileal segment protrud-
ized, one can often see additional findings of nonrotated small bowel [6, 8]. When com- ing through a defect in the cecal mesentery and
engorged vessels grouped together at the en- pared with the left paraduodenal hernias, extending into the right paracolic gutter [1, 9]
trance of the hernia sac, with the proximal those on the right are usually larger and are (Fig. 7). These hernias can therefore be subcat-
jejunal arteries showing an abrupt change of more often fixed [5]. egorized as either acquired or congenital de-
direction posteriorly behind the inferior me- Clinically, these hernias present in a simi- fects in the cecal mesentery.
senteric artery [6, 7] (Fig. 4F). The inferior lar manner to the left paraduodenal hernias Clinically, patients with pericecal hernias
mesenteric vein and ascending left colic ar- with chronic postprandial pain [5]. present in a similar manner to those with all
tery lie in the anterior and medial border of On a standard barium gastrointestinal ex- other types of internal hernias except for the
the left paraduodenal hernia and may be dis- amination, a larger and more fixed, encap- location of symptoms, which tends to be in
placed laterally (Figs. 2 and 4C). sulated, ovoid collection of bowel loops is the right lower quadrant, so that pericecal
noted lateral and inferior to the descending hernias are sometimes mistaken for appen-
Right Paraduodenal Hernia duodenum, in the right half of the transverse diceal abnormalities [1, 9]. A higher inci-
Right paraduodenal hernias have an over- mesocolon, or behind the ascending meso- dence of occlusive symptoms with rapid pro-
all incidence of approximately 13% and colon [1, 5, 9] (Fig. 6A). As opposed to the gression to strangulation is also commonly
occur when bowel herniates through left paraduodenal hernias, both the afferent found, with a mortality rate reported to be as
Waldeyer’s fossa (representing a defect in and efferent loops of bowel are closely op- high as 75% [9, 13].
the first part of the jejunal mesentery), be- posed and narrowed [1, 5]. With CT, an en- Imaging studies, including both barium
hind the superior mesenteric artery and in- capsulated cluster of small-bowel loops is and CT, show similar findings. These hernias
ferior to the transverse or third portion of the noted in the right mid abdomen, with loop- can often be confidently diagnosed as a clus-
duodenum (Fig. 5). This normal yet uncom- ing of the small bowel around the superior ter of bowel loops (usually ileal) located
mon recess is found in less than 1% of the mesenteric artery and vein at the root of the posteriorly and laterally to the normal
population and, like left paraduodenal her- small-bowel mesentery being seen occa- cecum, occasionally extending into the right
nias, the right paraduodenal hernia can be sionally [5, 8] (Fig. 6B). Small-bowel ob- paracolic gutter [1, 9] (Fig. 8). Again, there
classified as congenital type, normal aper- struction may be present with dilated loops will be evidence of small-bowel obstruction
ture subtype [1, 9]. In these situations, the containing air–fluid levels. Because right- and mass effect displacing the cecum anteri-
herniated contents are located in the right sided paraduodenal hernias are thought to orly and medially.

706 AJR:186, March 2006

 Radiographic and Clinical Findings of Hernias

A B

Fig. 3—Left paraduodenal hernias shown on upper gastrointestinal series, and

barium enema in one patient and lateral view of upper gastrointestinal series from
different patients.
A, 55-year-old man with gastrointestinal bleeding. Anteroposterior projection of oral
contrast small-bowel study shows cluster of small-bowel loops in left upper
quadrant, lateral to fourth portion of duodenum (arrow).
B, Barium enema study (anteroposterior projection) from same patient as in A
depicts inferior displacement of distal transverse colon and splenic flexure (arrow)
caused by mass in left upper quadrant that was later revealed to be left
paraduodenal hernia.
C, Lateral radiograph from upper gastrointestinal series in 35-year-old woman with
abdominal pain shows small-bowel loops (arrow) causing mass effect and
indentation on posterior aspect of stomach (S), displacing it anteriorly.
C

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 Martin et al.

Foramen of Winslow edge of the lesser omentum, the hepa- date lobe, and duodenum, respectively [14].
The foramen of Winslow is a normal com- toduodenal ligament (Fig. 9). The posterior, This hernia can therefore be subcategorized
munication between the greater and lesser superior, and inferior boundaries of this fo- as a congenital type, normal aperture sub-
peritoneal cavities, located beneath the free ramen include the inferior vena cava, cau- type. It constitutes 8% of all internal hernias,

A B

C D
Fig. 4—CT scans from six patients with left paraduodenal hernia.
A, Axial contrast-enhanced CT scan in 11-year-old boy shows small-bowel loops (arrows) between stomach (S) and pancreas (P).
B, Axial contrast-enhanced CT scan in 28-year-old man shows small-bowel loops (white arrow) behind pancreas (P) itself. Black arrow indicates stomach.
C, Axial contrast-enhanced CT scan in 36-year-old man shows small-bowel loops (arrows) displaying inferior mesenteric vein (arrowhead) to left.
D, Coronal reconstruction of contrast-enhanced CT data set in 28-year-old man shows small-bowel loops between transverse colon (T) and left adrenal gland (arrow).
(Fig. 4 continues on next page)

708 AJR:186, March 2006

 Radiographic and Clinical Findings of Hernias

E F
Fig. 4 (continued)—CT scans from six patients with left paraduodenal hernia.
E, Unenhanced axial CT scan in 35-year-old man shows evidence of small-bowel obstruction of herniated contents as multiple loops of dilated small bowel (arrow) with
fluid–fluid levels noted.
F, Axial contrast-enhanced CT scan in 23-year-old man shows multiple engorged and prominent vessels (arrow) in herniated sac caused by vascular congestion and
obstruction.

elongated right hepatic lobe (such as a

Riedel’s lobe), which is thought to direct the
mobile intestinal loops toward the foramen
of Winslow [1, 5, 6, 9, 14, 15].
The typical patient is middle-aged, with
acute onset of severe, progressive pain and
signs of small-bowel obstruction [1]. Patients
also often present with symptoms of a proxi-
mal bowel obstruction, which are caused by a
pressure effect on the stomach by the herni-
ated contents [14]. Symptom onset is often
preceded by a change in intraabdominal pres-
sure, such as parturition or straining [1, 5].
Occasionally, forward bending provides some
relief [1]. Rarely, patients will present with
Fig. 5—Graphic jaundice or a distended gallbladder, again
illustration of right from pressure or stretching of the common
paraduodenal hernia
shows loop of small bile duct by the herniated colon [5].
bowel prolapsing When the small bowel herniates, conven-
(curved arrow) through tional radiographs may reveal a circum-
Waldeyer’s fossa, behind
superior mesenteric
scribed collection of gas-filled loops in the
artery (straight arrow) upper abdomen, medial and posterior to the
and inferior to third stomach, which may progress to a location
portion of duodenum anterior to the hepatic flexure [1, 5, 9]. Evi-
(asterisk).
dence of small-bowel obstruction will prob-
ably be seen [1, 5]. With barium studies, ad-
ditional mass effect will likely be shown
with approximately two thirds containing 14]. Risk factors for this type of hernia in- because the stomach and the first and second
small bowel alone, and the remaining one clude an enlarged foramen of Winslow, an parts of the duodenum will shift anteriorly
third containing additional cecum and as- abnormally long small-bowel mesentery, and laterally [1, 5, 14] (Figs. 10A and 10B).
cending colon and occasionally gallbladder, persistence of the ascending mesocolon al- On occasion, this type of hernia can have the
transverse colon, and omentum [1, 5, 6, 9, lowing marked mobility of bowel, and an appearance of a cecal volvulus if the herni-

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 Martin et al.

A B
Fig. 6—23-year-old man with abdominal pain.
A, Anteroposterior projection from oral contrast small-bowel study reveals cluster of small-bowel loops (asterisk) posterior and lateral to second and third portions of
duodenum (arrow).
B, Contrast-enhanced CT scan shows abnormal loop of small bowel (arrow) in right upper quadrant and reveals right paraduodenal hernia.

plications can arise if defects exist in the gas-

trocolic or gastrohepatic omentum, allowing
reentry of herniated loops into the greater
peritoneal cavity.
Foramen of Winslow hernias often
present a similar radiographic appearance to
that of left paraduodenal hernias. One key
feature that can be useful in distinguishing
between these entities is the presence of an
encapsulating membrane seen with left
paraduodenal hernias and not with those in-
volving the foramen of Winslow. In addi-
tion, if the entry point can be identified, it
Fig. 7—Diagrammatic will be slightly inferior and to the left of the
illustration of pericecal
hernia shows loop of spine, delineated anteriorly by the inferior
ileum prolapsing (arrow) mesenteric vein and the left colic artery with
through cecal left paraduodenal hernias, whereas with fo-
mesenteric defect,
behind and lateral to
ramen of Winslow hernias, the entry point
cecum, into right will be relatively superior and to the right of
paracolic gutter. the spine, delineated by the liver hilum an-
teriorly. Along the same lines, mass effect
on the transverse colon more commonly in-
dicates a left paraduodenal hernia, again be-
ated sac contains cecum [1, 5, 14] (Fig. 11). tween the stomach and pancreas, with taper- cause of its more inferior location. Occa-
The zone of transition of the obstruction is ing of the herniation through the foramen of sionally, left paraduodenal hernias can be
usually located near the hepatic flexure [1]. Winslow [9] (Fig. 10C). There may be ante- supracolic. Finally, prominent, congested
On CT, multiple gas-filled loops are located rior and lateral displacement of the stomach blood vessels have more commonly been
in the lesser sac, posterior to the liver hilum, and stretching of the mesenteric vessels described with paraduodenal hernias, al-
anterior to the inferior vena cava, and be- through the foramen of Winslow [6]. Com- though not exclusively.

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 Radiographic and Clinical Findings of Hernias

Fig. 8—60-year-old man

with right lower quadrant
pain.
A, Single anteroposterior
radiograph from barium
enema study shows retro-
grade filling of herniated
distal ileum (arrows) as
loops of ileum pass poste-
rior to cecum (C) through
defect of ileocecal
mesentery to reach right
paracolic fossa.
(Reprinted with permis-
sion from [1])
B, Contrast-enhanced
axial CT scan shows loops
of small bowel (arrow)
posterior and lateral to
cecum (asterisk) in right
paracolic gutter, produc-
ing small-bowel obstruc-
tion. (Courtesy of Ghahre-
mani GG, San Diego, CA)
A B

fore consists of a hernial sac that lies within the

sigmoid mesocolon [16]. Both the second and
third types are acquired subtypes of internal
hernia, whereas the first is a normal congenital
subtype. However, these three types are radio-
graphically difficult to distinguish, and differ-
entiation is not so important because they are
treated surgically in a similar manner [9].
Clinically, these hernias present as de-
scribed, with no distinctive or characteristic
findings on history or physical examination.
If the patient has no evidence of obstruction,
these hernias can be diagnosed with postevac-
Fig. 9—Graphic
illustration of foramen of uation barium enema radiographs, which will
Winslow hernia shows show sacculated ileal loops occupying the left
bowel about to prolapse lower quadrant and elevation and displacement
(arrow) into lesser sac,
behind hepatoduodenal
of the sigmoid colon to the right [17]. If ob-
ligament, the free edge of struction is present, however, CT findings in-
the lesser omentum. clude a cluster of Y- and X-shaped dilated
small-bowel loops entrapped behind the left
posterior and lateral aspect of the sigmoid co-
lon, with the defect most commonly located
Sigmoid-Related Hernias second type, the transmesosigmoid hernia, oc- between the sigmoid colon and the left psoas
Two or three main types of sigmoid-related curs when small bowel herniates through a muscle, or between sigmoid loops if it is an in-
hernias are seen, depending on the degree of complete defect involving both layers of the tersigmoid type [4, 17] (Fig. 13). These bowel
adherence to the definition of internal hernia sigmoid mesocolon to lie in a position poster- loops often cause mass effect, displacing the
[5, 16]. The most common and most disput- olateral to the sigmoid itself [1, 9, 16] sigmoid colon anteromedially [17]. Additional
able, the intersigmoid type, develops when (Fig. 12). In this type of hernia, the orifice is findings of mesenteric vessel congestion and
herniated bowel, usually ileum, protrudes into usually a long slit with its edge bounded by stranding of the fat, suggesting strangulation,
the intersigmoid fossa, formed between two branches of the inferior mesenteric artery [5]. may be seen [17].
adjacent sigmoid segments and their respective The third and least common type, the intrame-
mesenteries [9]. Although this fossa is found at sosigmoid hernia, is herniation of viscera Transmesenteric Hernias
65% of autopsies [1], it is debatable whether through an incomplete defect involving only Although previously an uncommon type of
the opening of this fossa truly is an aperture. one of the layers (usually the left leaf) of the hernia, transmesenteric hernias are increasing
These hernias are often easily reducible [1]. A mesosigmoid [1, 9, 16]. The third type there- in incidence and surpassed the frequency of

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 Martin et al.

paraduodenal hernias in one study [4, 7, 10]. cause to prenatal intestinal ischemia and sub- However, there is a second peak of occur-
These hernias have a bimodal distribution, oc- sequent thinning of the mesenteric leaves rence in the adult population, and in this sub-
curring in both pediatric and adult patients. In because the prenatal intestinal ischemia is as- set of patients, the cause is iatrogenic, usually
children, transmesenteric hernias are the most sociated with bowel atresia in 5.5% of the pe- related to prior abdominal surgery, especially
common type of internal hernia, occurring in diatric population [1, 2, 5, 18]. Other causes with Roux-en-Y anastomosis, trauma, or in-
35% of this patient population [1, 5, 9, 18]. In postulated include intraperitoneal inflamma- flammation [1, 5, 6, 9, 18]. Both liver trans-
this age group, they are thought to arise from tion, trauma, partial development regression, plantation and the most common type of gas-
a congenital defect in the small-bowel mesen- and fenestration of the mesentery by the colon tric bypass surgery involve the formation of a
tery, near the ileocecal region or ligament of during the embryologic displacement into the Roux-en-Y loop at the choledochojejunos-
Treitz [1, 5, 9]. One popular theory relates the umbilical cord [6]. tomy site, and these procedures are increasing

A B
Fig. 10—54-year-old woman with abdominal pain.
A, Anteroposterior radiograph from upper gastrointestinal series shows abnormal
cluster of small-bowel loops located in lesser sac, representing foramen of Winslow
internal hernia.
B, Oblique lateral view from same gastrointestinal series shows abnormal cluster of
small-bowel loops posterior to stomach (asterisk), indenting (arrows) and displacing
stomach anteriorly.
C, Contrast-enhanced axial CT scan shows cluster of small-bowel loops (arrow)
located in lesser sac, posterior to stomach (arrowhead).

712 AJR:186, March 2006

 Radiographic and Clinical Findings of Hernias

A B
Fig. 11—70-year-old man with severe epigastric pain.
A, Anteroposterior projection of radiograph shows large collection of gas in left upper quadrant (arrows).
B, Barium enema (anteroposterior view) shows large, air-filled structure in upper abdomen (arrows), originally thought to represent a distended stomach but surgically
confirmed to be cecum involved in foramen of Winslow hernia.

Fig. 12—Diagrammatic illustration of intersigmoid hernia shows bowel protruding Fig. 13—85-year-old man with abdominal pain. Axial CT scan of sigmoid-related hernia
(arrow) through defect in sigmoid mesocolon to lie posterolateral to sigmoid (type 2, transmesosigmoid) reveals small-bowel loops (arrow) protruding through
colon itself. defect in sigmoid mesocolon, which usually occurs between left psoas muscle
(arrowhead) and sigmoid colon (S), to lie posterior and lateral to sigmoid colon itself.

AJR:186, March 2006 713

 Martin et al.

40%, respectively, with mortality rates of

a

Fig. 14—Diagrammatic
illustration shows 50% for the treated groups and 100% for the
retrocolic Roux-en-Y
procedure, with loop of nontreated subgroups [5–7, 18]. Volvulus and
small bowel about to strangulation or ischemia may be partly
herniate through caused by the usual small aperture of the de-
transverse mesocolon
(arrow) at surgically
fect (2–5 cm) in addition to the lack of encap-
created defect, in keeping sulation of the herniated loops, allowing a
with transmesocolic large length of small bowel to herniate
internal hernia. through the mesenteric defect [5, 18].
Clinically, in both the pediatric and adult
populations, patients present with signs and
symptoms of small-bowel obstruction, with
periumbilical, crampy pain, nausea, and dis-
tention [1, 7, 10]. Vomiting can be a less
prominent feature than with other types of
internal hernias because of fewer gastric and
enteral secretions from the proximal gastric
pouch or Roux limb that can accumulate
above the level of obstruction [15]. Overall,
however, symptom onset is often more acute
than with other types of hernias [6]. Most
(93%) transmesenteric internal hernias in
the adult postoperative population occur
more than 1 month after surgery (mean, 235
days), and the most common cause of ob-
struction during the first postoperative
month is adhesions [4]. On physical exami-
nation, the “Gordian knot of herniated intes-
tine” has been described, representing a ten-
der abdominal mass [1].
Transmesenteric hernias are more difficult to
diagnose on imaging studies because their ap-
pearance and location are more variable. This is
partly because of the lack of a confining sac and
in frequency (Fig. 14). If the Roux loop is surgery [15]. The second type of transmesen- therefore their potential location anywhere in
placed anteriorly to the transverse colon, re- teric internal hernia occurs when bowel pro- the peritoneal cavity, although they tend to occur
ferred to as antecolic, there will be no defect lapses through a defect in the small-bowel more commonly in the right mid abdomen [6, 9,
created in the transverse mesocolon; however, mesentery. Finally, the third type, known as 10]. Most commonly, it is the Roux loop itself
this procedure is less commonly performed the Peterson type, has also been described and that herniates with a cluster of a few loops of di-
because of the required long segment of involves the herniation of small bowel behind lated small bowel in the expected location of the
bowel needed to travel around the transverse the Roux loop before the small bowel eventu- Roux loop [4] (Fig. 15). On radiography, there
colon to finally be anastomosed to the re- ally passes through the defect in the trans- may be signs of small-bowel obstruction, occa-
maining gastric pouch. A more direct route verse mesocolon [4]. sionally with a closed loop appearance [18].
involves creating a defect in the transverse Several predisposing factors have been Although the transmesenteric hernia often
mesocolon, allowing a shorter Roux limb postulated. Although surgeons attempt to causes obstruction of the limb proximal to the
length. However, this second surgical proce- close the defects created, they can be incom- enteroenterostomy site, if the hernia is distal,
dure, also known as a retrocolic type, is more pletely closed or can have a breakdown or a an important clue may be the presence of sig-
associated with the potential complication of pulling of the suture material through the me- nificant air in the gastric remnant, which is
internal hernia (Fig. 14). Interestingly, inter- socolic fat [3, 15]. Enlargement of the mesen- only a normal finding in the early postopera-
nal hernias also appear to occur more com- teric defect can occur with repeated hernia- tive course (Fig. 16). Otherwise, this finding
monly after laparoscopic Roux-en-Y gastric tion. An additional possible predisposing is of concern for a distal obstruction at or be-
bypass than after open Roux-en-Y gastric by- factor may be the rapid weight loss and de- yond the enteroenterostomy site.
pass, for reasons unknown [15]. creased intraperitoneal fat that occurs in bari- Oral contrast material and cross-sectional
Three main types of transmesenteric inter- atric patients, causing enlargement of the de- studies will provide a variable appearance,
nal hernias are seen. The first and most com- fect [4]. Transmesenteric hernias are more depending on the type of transmesenteric her-
mon is the transmesocolic, which has been likely than other subtypes to develop volvulus nia and the segment and length of herniated
documented to occur in 0.7–3.25% of patients and strangulation or ischemia, the incidence bowel. If the hernia is of the first type,
after laparoscopic Roux-en-Y gastric bypass of which is reported to be as high as 30% and through the mesocolon and consisting of only

714 AJR:186, March 2006

 Radiographic and Clinical Findings of Hernias

Fig. 15—40-year-old hepatic flexure that is displaced inferiorly and

woman with nausea and medially [6].
vomiting. Contrast-
enhanced axial CT scan The second described finding, again by the
of transmesenteric same authors [6, 7], involves displacement of
internal hernia 19 months the overlying omental fat, with the obstructed
after Roux-en-Y
procedure shows dilated
loops compressed and directly abutting the ab-
loops of duodenum (large dominal wall (Fig. 17B). It has been suggested
black asterisk) and that these two findings of peripherally located
jejunum (white asterisk) small bowel and lack of omental fat between
in expected location of
Roux loop. Note that the loops and the anterior abdominal wall
Roux limb (arrowhead) is might be the most helpful CT signs, with an
compressed. Straight overall sensitivity of 85% and 92% for each re-
arrows, curved arrow,
and small black asterisk spective finding [7]. The mesenteric vascula-
represent colon. ture may also show an abrupt change in the
(Reprinted with course of the superior mesenteric artery, which
permission from [19])
is often displaced to the right, with crowding,
stretching, engorgement, and displacement of
its visceral branches [5, 6, 10, 18]. However,
further studies concluded that the only statisti-
cally significant signs were relatively nonspe-
cific findings of small-bowel dilatation with
transition point, clustering of small-bowel
loops, and mesenteric vessel abnormalities (in-
cluding displacement of the main mesenteric
trunk to the right), obtaining an overall average
sensitivity of 63%, specificity of 73%, and ac-
curacy of 77% [10]. Again, a “closed loop”
Fig. 16—36-year-old man sign, twisting of the mesenteric vessels and the
with sudden onset of
abdominal pain.
whirl sign if volvulus is present, may also be
Radiograph seen [1, 6, 9]. Occasionally, there may even be
(anteroposterior evidence of ischemia with ascites and bowel
projection) shows wall thickening present [7].
distended air-filled
gastric remnant, which is With the third type of transmesenteric
normal finding in recently hernia associated with Roux-en-Y surgery,
postoperative patient. known to surgeons as the Peterson type, little
However, in this patient
several months after has been described in the imaging literature
surgery, this finding is other than nonspecific findings of partial
most worrisome for small-bowel obstruction and crowding of the
obstruction at distal
mesenteric vessels.
anastomosis of Roux-en-
Y loop. As previously mentioned, because of their
variable imaging appearances, transmesen-
teric hernias are often confused with either
right paraduodenal or pericecal hernias. One
helpful distinguishing feature for the former
a few loops of small bowel, oral contrast stud- ated segment is much longer or is of the sec- includes the presence of an encapsulating
ies may show a beaked appearance of both the ond type, through the small-bowel mesentery. membrane, which should be seen only with
afferent and efferent loops and resultant mass On CT, more typical findings have been de- right paraduodenal hernias. Differentiating a
effect on the stomach and transverse colon, scribed, in addition to the usual findings of pericecal hernia from a transmesenteric her-
simulating a left paraduodenal hernia [5]. small-bowel obstruction with transition point nia can be more problematic. Location of her-
With CT as with barium studies, these hernias [6]. As described by Blachar and Federle [6] niated bowel loops (in the right upper quad-
can often be mistaken for or occur concomi- and Blachar et al. [7], the presence of clus- rant for transmesenteric and right lower
tantly with a small-bowel volvulus and closed tered bowel loops in the periphery of the peri- quadrant for pericecal) can sometimes pro-
loop obstruction, including a beaklike appear- toneal cavity, lateral to the colon (a reversal of vide a clue, although usually a history of sur-
ance of the closely opposed afferent and effer- the normal pattern), with central, inferior, and gery is the most helpful information.
ent loops [9, 18]. Again, there may be mass posterior displacement of the transverse colon
effect on the stomach and transverse colon. is one clue (Fig. 17A). Because, as previously Retroanastomotic Hernias
On the other hand, a slightly different ra- mentioned, the herniated bowel is located Retroanastomotic hernias occur when small-
diographic picture will emerge if the herni- more commonly on the right, it is often the bowel loops herniate posteriorly through a de-

AJR:186, March 2006 715

 Martin et al.

A B
Fig. 17—CT scans in two different patients with transmesenteric internal hernias.
A, Contrast-enhanced axial CT scan of 84-year-old woman showing transmesenteric internal hernia after Roux-en-Y procedure shows dilated, fluid-filled loops of small bowel
lateral to ascending colon (arrow) and displacing omental fat because loops of bowel lie directly beneath anterior abdominal wall (arrowheads).
B, Axial contrast-enhanced CT scan at level of transverse mesocolon in a 40-year-old woman shows dilated loop of jejunum directly abutting anterior abdominal wall (white
asterisk). In addition, note compression of pancreaticobiliary limb (straight arrows), whereas Roux limb (small arrowhead) is barely visible. Large arrowhead, black asterisk,
and curved arrow indicate colon. (Reprinted with permission from [19])

retroanastomotic space. However, if antecolic

surgery is performed, the afferent loop will be
the most commonly involved segment.
As opposed to the transmesenteric type of
internal hernia related to the Roux-en-Y sur-
gery, the retroanastomotic type tends to occur
most commonly during the first postoperative
month, with half of all cases presenting during
this time [1, 5]. Of the remaining 50%, half
will occur after the first year, and the other half
Fig. 18—Diagrammatic (or 25% of the total) will occur between
illustration shows months 2 and 12 [5]. Also in contradistinction
retrocolic Roux-en-Y to the transmesocolic type, the retroanasto-
gastric bypass
procedure. Arrow motic hernia is more common with the ante-
indicates loop of small colic form of the surgery. Symptoms again de-
bowel protruding pend on whether the retrocolic or antecolic
posterior to
enteroenterostomy, in form of the surgery was performed. If retro-
keeping with a colic, symptoms may be nonspecific findings
retroanastomotic related to a high small-bowel obstruction, such
internal hernia.
as crampy abdominal pain and nausea [1, 5].
Typically, there is less vomiting because of the
relative lack of fluid and secretions in the gas-
tric pouch or Roux limb [19]. On physical ex-
amination, there may be a tender mass in the
fect related to a surgical anastomosis; they are ligament of Treitz inferiorly, and the gastroje- left upper quadrant [1]. With the antecolic
therefore by definition considered an acquired junostomy site and afferent limb of the jejunum form of the surgery, patients more commonly
type, abnormal aperture subtype of internal her- anteriorly; hence the term “retroanastomotic” present with persistent epigastric pain and ten-
nia. Specifically, these hernias have been most [5] (Fig. 18). The most common herniated loop derness, nonbilious vomiting, and increased
commonly described with the Roux-en-Y for- consists of the efferent jejunal segment, which amylase [1]. Compared with other types of in-
mation and are ever increasing in incidence as occurs in approximately 75% of cases [1]. ternal hernias, these hernias are less likely to
liver transplantations and gastric bypasses for However, controversy exists in the literature as present with strangulation because of the large
bariatric surgeries continue to become more to whether this occurs more commonly with the aperture size. However, uncommonly, compli-
frequent and widespread. If the surgery is of the antecolic [5] or retrocolic [1] form of the sur- cations can arise when the herniated loop reen-
antecolic type, the borders of the aperture con- gery. Less commonly, a very long afferent limb, ters the greater peritoneal cavity through the
sist of the transverse mesocolon superiorly, the ileum, cecum, or omentum can herniate into the foramen of Winslow or a gastrohepatic or gas-

716 AJR:186, March 2006

 Radiographic and Clinical Findings of Hernias

A B
Fig. 19—CT scans from two different patients showing retroanastomatic hernias.
A, Contrast-enhanced axial CT scan of retroanastomotic hernia in 35-year-old woman shows loops of dilated fluid-filled small bowel (arrow) in left upper quadrant.
B, Axial CT scan in 58-year-old woman 2 months after Roux-en-Y gastric bypass shows herniated loop posterior to jejunojejunostomy site (straight arrow) and dilated proximal
Roux limb (large arrowheads). Note decompressed distal ileal loops (small arrowheads) and colon (curved arrows). (Reprinted with permission from [19])

trocolic ligament [5]. Diagnostic consider- congenital to iatrogenic causes. It is important 9. Mathieu D, Luciani A. Internal abdominal hernia-
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