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Hernia through the Perirectal Fossa
经直肠旁隐窝疝
We found no reports of internal hernias through a defect of the perirectal fossa and only three reports of internal hernias through the pouch of Douglas in the English-language literature (57–59). The pouch of Douglas is a peritoneal reflection between the uterus and the rectum, and its depth varies extensively; an abnormally deep pouch of Douglas may lead to a posterior perineal hernia (59,60). These defects are believed to be congenital without abnormality of the pouch of Douglas or the pelvic floor musculature. In our patient, approximately two-thirds of the circumference of the antimesenteric ileal wall was involved through a defect of the right perirectal fossa in a Richter hernia (Fig 18). This peritoneal defect was also believed to be congenital without abnormality of the perirectal fossa or the pelvic floor musculature.
我们没有找到经直肠旁隐窝缺口导致的腹内疝的报道，只发现了3例经子宫直肠陷窝的腹内疝的英文文献报道。子宫直肠陷窝是腹膜在子宫和直肠处的反折，其深度变化很大；子宫直肠陷窝过深可导致会阴后方的疝。这些缺口被认为是先天性的，没有子宫直肠陷窝或骨盆底部肌肉组织的异常。在我们的这例Richter 疝（腹壁疝）中，大约2/3周的系膜游离壁的回肠壁经右侧直肠隐窝的缺口疝出（图18）。这种腹膜缺口也被认为是先天性的，没有子宫直肠陷窝或骨盆底部肌肉组织的异常。

Figure 18. Hernia through a defect of the right perirectal fossa in a 28-year-old woman with continuous lower abdominal pain of 34 hours duration. (a, b) Contrast-enhanced CT scans of the pelvis (b obtained 10 mm below a) show dilated and fluid-filled small bowel loops (S). A cluster of dilated bowel loops (arrow) is located to the right of the rectum (R) and behind the uterine cervix (U). Laparotomy was performed 4 hours after CT. (c) Drawing (superior view) of the surgical findings shows that the antimesenteric wall of an ileal loop (I), located 50 cm from the ileocecal valve, was herniated (Richter hernia) through a defect (arrow) in the anterior peritoneal layer of the right perirectal fossa (arrowheads). When withdrawn manually, the incarcerated bowel loop was viable and nongangrenous. R = rectum, U = uterus.
一28岁妇女经右侧直肠旁隐窝的腹内疝，表现为下腹部持续疼痛34小时。（a，b）盆腔CT增强扫描（图b低于图a 10mm）显示小肠肠管（S）扩张，肠管内积液。扩张肠管堆积（箭头）位于直肠右侧宫颈（U）后方。CT检查4小时后行剖腹手术。（c）术中所见的示意图（上面观）显示位于回盲瓣50mm的回肠系膜的游离壁（I）经右侧直肠旁隐窝（长箭头）的前腹膜层上的缺损（短箭头）疝入（Richter疝）。

Relationship of CT Findings to Clinical Findings and Management
CT表现与临床表现和治疗的相关性
Internal hernias are uncommon and are rarely preoperatively diagnosed because there are no specific clinical symptoms. The most common clinical presentation is bowel ischemia with some degree of SBO. However, if hernias are easily reducible, the clinical presentation may be intermittent or transient. During asymptomatic intervals, clinical or radiologic studies may reveal no abnormality (9,10).
腹内疝并不常见，没有特异性的临床症状，所以很少能在术前诊断。最常见的临床表现是肠管局部缺血和不同程度的SBO，然而如果疝能较容易回复，其临床表现可以是间歇性的或暂时的。在没有症状期间，临床和放射学检查并不能发现异常。

In acute-onset and high-grade SBO, some investigators have recommended direct surgical exploration, whereas partial obstruction can initially be managed with conservative treatment (4,11,12). Nevertheless, even if the affected bowel loops at the abnormal anatomic location are not dilated and small internal hernias with low-grade obstruction are detected, we recommend that surgical colleagues use appropriate care to decrease hernial strangulation. Examples of such care include carefully monitoring the patient’s vital signs and physical examination results or performing follow-up CT or gastrointestinal studies enhanced with intraluminal contrast material, including CT enteroclysis.
对于急性发作的和重度的SBO，一些研究者推荐直接手术探查，即使部分性的肠梗阻能在早期进行保守治疗。尽管处于异常解剖部位的受累肠管没有扩张，腹内疝较小，梗阻程度较轻，我们也推荐外科同事给予适当的护理减小疝性绞窄，例如详细的监护病人生命体征、进行体格检查、复查CT、使用管腔内造影剂的胃肠增强检查，包括CT肠造影术。

Conclusions
结论
Understanding the anatomy of the peritoneal cavity and the characteristic anatomic location of each internal hernia, as well as recognition of the characteristic CT findings, may assist in consideration or identification of internal hernias in most cases of SBO. Currently, multi–detector row CT is most often recommended to detect the cause of SBO and to facilitate diagnosis of a variety of internal hernias. Therefore, appropriate guidance of surgical colleagues by radiologists may be essential to avoid irreversible damage to the bowel wall and mesentery.
对腹腔解剖和各型腹内疝特征性的解剖部位的了解以及对特征性CT表现的识别有助于了解或识别大多数SBO病例中的腹内疝。当前，多层螺旋CT最备受推荐用于发现SBO的病因并能促进各型腹内疝的诊断，因此放射科医师对外科同事的适当指导对避免肠壁和肠系膜的不可逆损伤很有必要。


编辑：bluelove