Internal hernia due to mesenteric defect

Lesser omental hernia without intestinal gangrene - Case report

INTRODUCTION

There are several types of internal hernia. Herniation through the defect in the lesser omentum is extremely rare. Symptoms of this type of hernias may vary a lot and diagnosis is difficult. In this case report a young adult with nonspecific symptoms is diagnosed with an intestinal herniation through the defect in the lesser omentum.

CASE PRESENTATION

A 35-year-old man with the history of laparoscopic colectomy presented with abdominal pain but no symptoms of peritonitis or acute bowel obstruction. Abdominal computed tomography (CT) revealed displacement of mesenteric vessels, small intestine and stomach. Intestinal herniation through the lesser omentum was suspected. Laparoscopic reposition of small intestine was performed. The greater curvature of the stomach was sutured to the transverse mesocolon to prevent recurrence of hernia.

DISCUSSION

Previous surgery, low body mass index (BMI), absence of adhesions may predispose the lesser omental hernia. Herniating of intestines through the large openings may occur without presence of acute obstruction or gangrene. CT is helpful in making a correct diagnosis.

CONCLUSION

When evaluating the patient with abdominal pain, internal hernia should be considered. CT modalities may aid in the detection of these rare hernias and ensure timely treatment. Perioperative inspection and repair of the hepatogastric ligament may help to prevent lesser omental hernias.

Transmesenteric hernia with closed-loop small bowel obstruction: A case report

Background

Transmesenteric hernia is a subtype of internal abdominal hernia (IAH) and a rare cause of small bowel obstruction in adults. Difficulty in reaching a definitive diagnosis due to non-specific clinical and imaging findings often cause life-threatening bowel ischemia.

Case report

We report a case of a 37-year-old female who presented with clinical and imaging features of small bowel obstruction. She underwent an emergency laparotomy where the diagnosis of transmesenteric hernia causing closed-loop obstruction was made. The non-viable portion of the intestine was resected, anastomosis of the ileum along with the closure of the mesenteric defect was performed.

Discussion

IAH is the protrusion of abdominal viscera, most commonly small bowel loops through a peritoneal or mesenteric defect into the abdominal or pelvic cavity. Considered common in children, it is rare in adults and is most common after abdominal surgeries like Roux-en-Y gastric bypass surgery. Clinical features and imaging findings are non-specific causing delay in the diagnosis.

Conclusion

A high index of suspicion is required while assessing the patient with symptoms suggestive of acute bowel obstruction as the preoperative diagnosis of a transmesenteric hernia is challenging.

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Transmesenteric hernia causing small bowel obstruction in the adult is rare.

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Diagnosis is often delayed due to non-specific clinical and imaging features.

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Careful exploration of the whole mesentery after reduction of hernia can prevent recurrences.

Congenital Transmesenteric Hernia-Importance of a Timely Intervention

Transmesenteric hernia is a rare cause of small bowel strangulation in adults. Our patient was a 61-year-old previously healthy male, who presented with vomiting and abdominal pain with no surgical history and no trauma in the past. Computed tomography with contrast enhancement was suggestive of superior mesenteric vein (SMV) compression without any obvious cause. The emergency exploratory laparotomy revealed venous congestion of small bowel caused by a transmesenteric hernia with the herniated loop compressing the SMV. On reducing the hernia, complete reversal of the bowel congestion was noted and small bowel resection was averted. A high index of suspicion for a transmesenteric hernia in small bowel obstruction of unknown etiology and a timely surgical intervention are must for a good clinical outcome.

Adhesive and non-adhesive internal hernia: clinical relevance and multi-detector CT images

Internal hernia (IH)-related surgical acute abdomen is not well understood because of the rarity of cases and underdiagnosis. This study was performed to further understand the clinicopathological features and multi-detector computed tomography (MDCT) findings of IH in cases confirmed by surgery. In all, 51 patients with a definite diagnosis of IH confirmed during surgical exploration from Feb. 2012 to Feb. 2018 in our hospital were included in this research. Medical records, including MDCT images and intra-operative findings, were collected retrospectively. In all, 39 and 12 cases were categorized as adhesive IH (76.5%) and non-adhesive IH (23.5%), respectively. Among the patients with adhesive IH, 73% had a history of abdominal or pelvic surgery. Additionally, the mesentery was the most common component of adhesive bands (64.1%). Congenital peritoneal abnormalities and gastrointestinal reconstruction were the main causes of non-adhesive IH.As a specific sign, the fat notch sign was much more common in adhesive IH than in non-adhesive IH (P = 0.023). Bowel wall thickening (P = 0.041), abnormal bowel wall enhancement (P = 0.006) and twisted bowels with the vessel swirl sign (P = 0.004) were indicators of bowel necrosis. Among all of the cases of IH, 34 (66.7%) were complicated by bowel necrosis, and 1 patient died. In conclusion, non-adhesive IH has different clinicopathological features and MDCT findings from those of adhesive IH. MDCT is a useful tool with high sensitivity for confirming IH and may help to guide the early treatment of IH.

Transmesenteric hernia with two mesenteric defects in an adult

Transmesenteric hernia is a rare cause of small bowel strangulation in adults and, to our knowledge, no one has reported the existence of two mesenteric defects in an adult. Our patient was a 73-year-old Japanese woman who presented to our emergency department complaining of abdominal pain and nausea. Computed tomography with contrast enhancement revealed a closed loop obstruction in the pelvis, suggesting small bowel strangulation due to an internal hernia. The emergency exploratory laparotomy indicated a small bowel strangulation caused by a transmesenteric hernia. With the examination across whole parts of the mesentery, we identified another small defect. Both defects were closed by suture intraoperatively, and the patient's postoperative course was satisfactory. Searching for whole parts of the mesentery after the reduction of a hernia can help prevent the recurrence of internal hernias.

Bowel obstruction without history of laparotomy: Clinical analysis of 70 patients

BACKGROUND

Determining the cause of bowel obstruction without a history of laparotomy (BO without HL) is difficult and can result in delay of treatment and development of a potentially life-threatening situation. We herein investigated the clinical characteristics of pediatric patients who underwent laparotomy due to BO without HL.

METHODS

All surgical pediatric patients aged <16 age who were diagnosed with BO without HL between January 2004 and September 2014 were included. Etiology of BO, intraoperative findings and postoperative outcome were investigated retrospectively.

RESULTS

Seventy patients were diagnosed with BO without HL in this period. In these 70 patients, malrotation (n = 34), intussusception (n = 19), internal hernia (n = 6) and Meckel's diverticulum (n = 5) were predominantly identified. Regarding preoperative definitive diagnosis, prevalence of internal hernia, Meckel's diverticulum or idiopathic volvulus was significantly lower than that of malrotation or intussusception (P < 0.05). Intraoperatively, the rates of strangulation and bowel resection were 55.7% and 30.0%, respectively. The optimal time for emergency operation in order to avoid strangulated bowel resection was <19 h from onset of symptoms.

CONCLUSIONS

Malrotation and intussusception are major causes of BO without HL in children, but internal hernia, Meckel's diverticulum and idiopathic volvulus should always be taken into account, particularly because of the preoperative diagnostic difficulty and resulting high rate of intestinal resection. In order to avoid resection of the bowel, surgery should be done within 19 h before bowel ischemic change occurs.

Congenital Defect in Lesser Omentum Leading to Internal Hernia in Adult: A Rare Case Report

Intestinal obstruction is one of the common clinical condition which is encountered in emergency room. Internal hernia is one of the rare causes of small bowel obstruction accounting for less than 1% of cases. A congenital omental defect is very rare, but can potentially cause internal hernia leading to obstruction or strangulation of the bowel. We present a case of a 54-year-old man who was brought to the emergency department with sudden onset of lower abdominal pain. He had no history of abdominal surgeries or history of trauma. An emergency laparotomy was performed. On exploring the abdominal cavity, the lesser omental defect was detected, 3cm in size. Loops of jejunum had gone through the defect. Congested bowel loop was pulled back and defect was approximated. An adult congenital omental defect is rare; however, it should be considered as one of the differential diagnoses in a relatively young patient with bowel obstruction without external hernia, previous abdominal surgery or trauma.

Rare Hernias Presenting as Acute Abdomen- A Case Series

Hernia is an abnormal protrusion of an organ or tissue through a defect in its surrounding walls. It can be divided into internal, external and diaphragmatic hernias. Most of them can be asymptomatic. If they become symptomatic they can present with features of intestinal obstruction, incarceration or strangulation. In this case series we compare the incidence of these rare presentations of hernias with world literature and to warn surgeons not to cut the obstructing band in cases of internal hernias. In this case series, we review the clinical details of 7 rare presentations of hernia, who presented with various types of hernias to a tertiary care centre in Kerala over a period of one year. Of these 7 cases 6 cases were internal hernias (3 left paraduodenal hernias, 2 transmesentric hernias, and 1 pericaecal hernia) and a case of spigelian hernia above the level of umbilicus. All of them presented as acute abdomen in the emergency department. Among these 7 cases, only one case was diagnosed preoperatively. Three patients had bowel gangrene and had to undergo resection- anastomosis of the bowel. The survival rate among these cases was 100% as compared to 50% in the world literature if they had been left untreated. Even though internal hernias are a rare entity, we need to have it as a differential diagnosis in case of intestinal obstruction, in a previously non-operated abdomen.

An unusual case of transverse mesocolic internal hernia with abnormality of both hands and high arched feet

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A case of internal abdominal herniation through a defect in transverse mesocolon with congenital abnormality of hands and feets.

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Reduction along with derotation of gut with closure of the rent and fixation of the caecum to lateral peritoneum done.

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Due to the risk of strangulation of the hernial contents, even small internal hernias are dangerous.

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Herniation through transverse mesocolon is very rare and preoperative diagnosis of mesenteric defect is difficult.

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Surgical decision-making is on the basis of clinical findings of intestinal strangulation or ischemia.

Introduction

An internal abdominal herniation is the protrusion of a viscus through a normal or abnormal mesenteric or peritoneal aperture. It is a rare cause of small bowel obstruction with a reported incidence of 0.2–0.9%. It can either be acquired through a trauma or surgical procedure or can be related to congenital peritoneal defects. Herniation through transverse mesocolon is very rare.

Presentation of case

A case of acute intestinal obstruction due to internal herniation through a congenital rent in transverse mesocolon with rotation of gut approximately 180° around axis of the band. Patient also had bilateral hypoplastic thenar muscles with rudimentary 1st metacarpals and high arched feet. Reduction along with derotation of gut, with closure of the rent in transverse mesocolon and fixation of the caecum to lateral peritoneum was performed.

Discussion

The preoperative diagnosis of mesenteric defect is difficult because of wide range of acute abdominal symptoms, and there are no specific radiographic findings. CT is the most important diagnostic tool is, with 77% accuracy in such cases. Due to the risk of strangulation of the hernial contents, even small internal hernias are dangerous and may be lethal.

Conclusion

Internal hernia should be suspected in patients with signs and symptoms of intestinal obstruction, particularly in the absence of inflammatory intestinal diseases, external hernia or previous laparotomy. Surgical decision-making is on the basis of clinical findings of intestinal strangulation or ischemia, and emergency laparotomy should be performed without preoperative diagnosis of such a rare disease.