Lesser sac hernia

Introduction of small omental sac Free small intestinal fistula, occasionally the long transverse mesenteric colon, through the retina hole (Winslow hole) into the small omental sac called herniaoflesseromentalbursa, or herniaofepiplonicforamen, because of the sac The anterior wall is the duodenal ligament, so most cases will be narrower. Occasionally, the intestinal fistula can also enter the small omental sac from the stenosis of the stomach ligament or the gastric ligament. The clinical manifestation is acute intestinal obstruction. It is a feature of leaning forward or knees to relieve abdominal pain. basic knowledge The proportion of illness: more common in the elderly, the incidence rate is 0.02% Susceptible people: no special people Mode of infection: non-infectious Complications: jaundice

Cause of small omental sac

(1) Causes of the disease

1. There are normal or abnormal holes between the small omental sac and the abdominal cavity, which is the anatomical basis of the small omental sac, such as the Winslow hole is too large, the small mesenteric or transverse mesenteric dysplasia appears local weakness or defect.

2. The swimming speed of the intestines is too large for the swimming of the large intestines. It is another important condition for the internal hemorrhoids to be transmitted through the small omentum. The common causes of excessive swimming of the intestines are:

(1) The small mesentery is too long. Usually, the intestines with large swimming in the abdominal cavity are small intestines. In the case of too long mesangial membrane, the abnormal activity will increase, so the organs that are clinically invaded are many. Small intestine.

(2) congenital intestinal malrotation: poor intestinal rotation can be accompanied by poor fixation of the midgut, which is an important cause of abdominal hernia.

3. Intestinal peristalsis abnormality, sudden increase of intra-abdominal pressure is the same as other intra-abdominal fistula. Under the influence of abnormal bowel movement after excessive bowel movement or overeating, sudden change of patient position and sudden increase of intra-abdominal pressure, the intestinal tube is easily The Winslow hole breaks into the small omental sac and forms a small omental sac.

(two) pathogenesis

1. Pathogenic process: The small omentum is a double peritoneum connected to the hepatic hilum and the small curvature of the stomach and the upper part of the duodenum. It can be divided into the right hepatoduodenal ligament and the left liver ligament. In the two parts, the only channel that communicates with the large ventricle and the large abdominal cavity is the retina hole (Winslow hole). The front boundary of the Winslow hole is the hepatoduodenal ligament, and the posterior boundary is the wall peritoneum covering the inferior vena cava. The upper boundary is The caudate lobe of the liver, the lower boundary is the upper part of the duodenum, generally can pass 1-2 fingers (Fig. 1), which is the most prone to occur in the small omental sac, if it is too large for some reason, it is the intestine The intrusion provides a "trick". Some people think that the Winslow hole is too large to pass or accommodate more than two fingers, which is the primary condition for the formation of Winslow.

The omentum is a bilayer peritoneum that extends from the beginning of the stomach and the beginning of the duodenum. The double omentum and transverse colon that extend under the large curvature of the stomach constitute the gastric collateral ligament (Fig. 1); The omentum reciprocates below the umbilical plane (forming the last two layers of the greater omentum) to the transverse colon and wraps it separately, which in turn forms the transverse mesenteric membrane, which may be due to incomplete fusion or omentum during embryonic development. Degeneration, or due to ischemic lesions, weak areas or hiatus, providing a pathological pathway for the development of post-natal abdominal organs and tissues into the small omental sac.

When the small mesentery is too long or has congenital intestinal malrotation, the swimming degree of the intestine will increase, increasing the chance of breaking into the Winslow hole and other holes. The former is mainly caused by small intestine intrusion, and the congenital intestine Poor rotation can be accompanied by poor fixation of the midgut, manifested as incomplete adhesion of the small mesentery, cecal ascending colon free, high cecum, omental adhesion, duodenal crypt enlargement and other pathological changes, so in addition to causing intestinal In addition to the torsion, the omentum can also be caused. The right colon and the transverse colon can also enter the small omental sac via the Winslow hole, especially when the omentum is incompletely attached, the right colon is incompletely depressed, and (or) the mesentery is too long. It is easy to happen.

The anterior wall of the ankle ring of the small omentum is the hepatoduo duodenal ligament, which has a common bile duct, a portal vein and a hepatic artery, and a posterior inferior vena cava and a spine. This structure is tough and dilatant, and it is easy to oppress through the iliac crest. The intestines of the ring make it difficult to recover, which easily leads to the incarceration and strangulation of the contents of the sputum.

2. Pathological classification: According to the path of intestinal fistula into the small omental sac, there are 4 types.

(1) Winslow sputum: The peritoneal organ enters the small omental sac via Winslow hole (Fig. 3), which is Winslow sputum, also known as small omental stenosis. The disease was first reported by Blandin (1834), according to statistics. 0.08% of sputum and 8% of sputum are rare in clinical practice. Males are more common. 63% of the contents are small intestine, 30% are terminal ileum and/or cecum, 7% are transverse colon, and very few are gallbladder and large net. Membrane, review literature, only reported in 2 cases in China, due to non-specific performance, patients diagnosed or suspected of less than 10% of the disease before surgery, the mortality rate is as high as 49%.

(2) Transverse mesenteric hiatus hernia: The intestine is inserted into the small omental sac from the transverse mesenteric hiatus.

(3) The hiatus of the liver and stomach ligament: The hiatus of the intestine is smashed into the small omental sac.

(4) Gastric colon ligament hiatus: The intestine is inserted into the small omental sac by the ligament ligament of the stomach.

Small omental sac prevention

Life is temperate, pay attention to rest, work and rest, and orderly life.

Small omental cystic complications Complications

1. The anterior wall of the ankle ring of Winslow's iliac crest is the hepatoduodenal ligament. The structure is strong and the expansion is small. The contents of the sputum are easily compressed and incarcerated and strangled.

2. Obstructive jaundice: The gallbladder and common bile duct are located in front of the duodenal ligament. When the small omental sac is sacral, the local pressure increases, and the anterior wall of the ankle ring compresses the common bile duct, resulting in obstructive jaundice.

Symptoms of small omental capsules Common symptoms Abdominal pain, upper abdominal pain, bloating, bloating, water, bowel sounds, disappearance, jaundice, nausea, vomiting, shock

1. Symptoms: This disease is mainly caused by acute intestinal obstruction. Patients may have upper abdominal pain, vomiting, and stop defecation and other symptoms.

(1) Abdominal pain: acute exacerbicular colic, more severe, unbearable, because the patient's body flexion when the anterior wall of the ankle ring (hepatic duodenal ligament) is relatively loose, can reduce abdominal pain, so patients often take a seat, Both knees flexed to the lower jaw. Some scholars believe that the reduction of abdominal pain during body flexion is a characteristic manifestation of Winslow's sputum, and some patients may feel low back pain.

(2) Vomiting and bloating: The degree is related to the organ that is invaded. If it is a bowel, the vomiting is severe. If the omentum, vomiting can be lighter, such as sputum into the upper part of the jejunum, vomiting occurs early, and frequent, abdominal distension is generally not obvious; if the organ is ileum or colon, vomiting occurs late, the degree of bloating is also More obvious.

2. Physical examination: The patient's upper abdomen is full, and the upper left abdomen often touches the soft cystic mass. The mass is fixed with tenderness. The early percussion is drum sound. After exudation, it is mostly dull sound, which can be heard and bowel sounds. Over-water sound, such as the disappearance of bowel sounds, or peritoneal irritation, or abdominal puncture, hemorrhagic turbid liquid, indicating that the intestine is strangulated or necrotic, severe cases may have shock performance, a small number of patients may be due to the anterior wall of the ankle ring Obstructive jaundice occurs when the common bile duct is compressed.

Examination of small omental sac

X-ray inspection

(1) Standing or supine abdominal plain film: If the content of the sputum is the intestine, the curved intestinal gas and gas-liquid plane can be seen in the small omental sac area, and the left front of the stomach can be displaced, which may be seen in the right abdomen. Small intestine fistula that rises to the direction of the lower Winslow hole in the liver. If the invagination contains the ascending colon, the intestines and fecal shadows are not seen in the right abdomen, but Erskine reports that in 13 patients with small omental hernia, 13 cases of small omentum There is no obvious gas-liquid level in the capsule area.

(2) Upper gastrointestinal angiography: It can be shown that the stomach is pushed to the left side, and the delayed angiography shows that the intestine is located in the small omental sac.

(3) Barium enema: When the invagination is colon, it can show that the colon is located in the small omental sac.

(4) CT scan: The main signs are:

1 The mesentery is located between the inferior vena cava and the portal vein.

2 There is a gas-liquid plane in the small omentum capsule, and it is pointed into the omentum hole.

3 The right abdomen has no ascending colon.

4 2 or more intestinal fistulas can be seen in the subhepatic space.

2. B-ultrasound examination: abnormal hepatic echo can be seen in the small omental sac area after the liver, the small omental sac, the common bile duct and the portal vein.

3.99mTc-HIDA cholangiography When the invagination is gallbladder, 99mTc-HIDA cholangiography can show gallbladder and abnormal biliary position.

Diagnosis and differentiation of small omental sac

Preoperative diagnosis of small omental sac is not an easy task. As far as the literature is reported, almost all cases need to be diagnosed by surgery to confirm the diagnosis. In addition to general intestinal obstruction symptoms and signs, patients with acute mechanical intestinal obstruction have the following conditions. When you should be alert to the possibility of the disease.

1. Acute episodes of upper abdominal cramps, which can be alleviated when the body is flexed or tilted forward.

2. The left upper abdomen often touches a tender cystic capsular with a fixed position.

3. Obstructive jaundice occurs.

4. X-ray inspection

(1) Intestinal fistula with flatulence in the upper abdomen, the activity of the affected bowel disappeared.

(2) Clustered small intestinal fluid levels can be seen in the small omental sac area.

(3) In addition to gas accumulation in the stomach, a circular gas area can be seen in the left upper abdomen.

(4) The stomach is pushed to the left or deformed by compression.

(5) The transverse colon is displaced downward.

(6) signs of mechanical intestinal obstruction.

Early paroxysmal colic with nausea and vomiting should be differentiated from cholelithiasis, acute gastric torsion, and acute pancreatitis.

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