bubble_chart Overview

Retroperitoneal hernia is a type of internal abdominal hernia, also known as retroperitoneal recess hernia. Retroperitoneal hernias are rare and include cases where abdominal contents pass through the mesentery, particularly the mesocolon and broad ligament, herniating into abnormal openings; hernias through the foramen of Winslow, congenital intestinal malrotation anomalies, and retroperitoneal hernias formed by abnormal peritoneal attachments creating peritoneal fold recesses. These hernias are commonly located around the duodenum, cecum, or sigmoid colon. There have been reports of retroperitoneal organs or tissues herniating into areas outside the retroperitoneum, but such cases are relatively uncommon.

bubble_chart Etiology

The formation of the hernia ring can be divided into congenital and acquired factors.

1. Congenital factors

are caused by the peritoneal recesses resulting from the rotation of the small intestine during the embryonic period. The peritoneal recesses can be further divided into: ① Paraduodenal Fossae; ② Intersigmoid Fossae; ③ Pericecal Fossae: which can be subdivided into: a. Ileocecal recess: located medial to the appendix and posterior to the ileum; b. Ileocolic recess: located medial to the ascending colon and superior to the ileum; c. Retrocecal recess. Clinically, hernias in the pericecal recesses are more common. Anatomically, these recesses belong to the range of the ileal mesentery, and the rotation of the ileum causes the peritoneum to fold, leading to the entrapment of intestinal loops. Comparatively, the ileocolic and ileocecal recesses have a higher incidence of herniation.

2. Acquired factors

In some recesses and their surrounding areas, hernia rings can form due to peritoneal defects caused by trauma or surgery. For example, during surgeries such as colorectal surgery, colostomy, or hysterectomy, if the defects between the stoma and the lateral peritoneum or the pelvic floor peritoneum are not properly sutured, retroperitoneal hernias can form.

bubble_chart Clinical Manifestations

A few patients show no obvious symptoms, while the majority present with acute intestinal obstruction, exhibiting symptoms such as abdominal pain, abdominal distension and fullness, vomiting, and fever. It often manifests as acute or chronic self-relieving intestinal obstruction, or a history of recurrent abdominal pain, or sudden onset of pain that gradually intensifies, accompanied by nausea, vomiting, abdominal distension and fullness, and the absence of gas or bowel movements. A localized mass may be palpable in the abdomen, which could have a history of several years, and tenderness may be present during episodes, with hyperactive borborygmi or high-pitched bowel sounds.

bubble_chart Auxiliary Examination

1. X-ray examination is somewhat helpful for diagnosis. According to Williams' opinion, the X-ray signs of retroperitoneal hernia mainly include: the dilated segment of the small intestine extends backward beyond the anterior edge of the spine, and from the side view, the small intestine accumulates or is disordered in abnormal areas. However, it must be differentiated from intestinal disorders caused by short mesentery, congenital intestinal malrotation, or postoperative adhesions that cause the intestines to cluster together. In some patients with retroperitoneal hernia, multiple groups of small intestine may be seen clustered together and cannot be separated from the palpable mass. In addition, X-ray examination may show that the affected intestinal loop has almost lost its mobility, and there is dilation, stasis, and gas accumulation, and occasionally a fluid level may appear. The proximal intestinal loop of the hernia may have dilated counterflow of liver qi peristalsis. Notches or displacement may sometimes be seen in the stomach or the intestine next to the hernia sac. Another characteristic is that the X-ray findings can vary greatly from one examination to another. Some people also perform mesenteric stirred pulse angiography, which is considered helpful for the diagnosis of retroperitoneal hernia.

2. Type B ultrasound can detect fluid-filled dark areas or identify obstructed intestinal loops.

bubble_chart Diagnosis

The preoperative diagnosis of this disease is challenging, and its definitive diagnosis can only be confirmed during surgery. However, misdiagnosis can also occur during surgery, where the retroperitoneal mass is mistaken for a malignant tumor or cyst. Due to the rarity of this condition and its deep-seated location, it is prone to misdiagnosis or confusion with fistula disease. Once it occurs, the consequences can be severe. If irreversible intestinal obstruction is detected, the possibility of an internal abdominal hernia should be considered, and surgical treatment measures should be actively pursued.

bubble_chart Treatment Measures

The treatment principle is early diagnosis and early surgery. The main risk of retroperitoneal hernia is causing intestinal obstruction, which accounts for approximately 0.9% of all intestinal obstructions. Acute intestinal obstruction should be treated with immediate surgery. Additionally, efforts should be made to actively correct typical edema, electrolyte, and acid-base imbalances to prevent intestinal loop necrosis. In cases of strangulation, the necrotic intestinal segment should be resected, end-to-end anastomosis performed, and the peritoneal defect repaired to prevent recurrence.

bubble_chart Complications

Complications such as water-electrolyte and acid-base imbalance, toxic shock, and intestinal ischemia and necrosis occurred.