A spontaneous strangulated transomental hernia: Prospective and retrospective multi-detector computed tomography findings

Spontaneous transomental hernia: a rare cause of closed loop bowel obstruction

Transomental hernias are the rarest subtype of internal hernias, accounting for 0.5%-3% of bowel obstructions. We report an unusual case of a spontaneous transomental hernia in a 47-year-old male presenting with non-specific obstructive symptoms. A CT scan revealed a closed-loop small bowel obstruction, but the diagnosis of a spontaneous transomental hernia was confirmed during emergency diagnostic laparoscopy. The small bowel remained viable, avoiding the need for resection, and the patient had an uncomplicated postoperative recovery. Clinical suspicion for transomental hernias is crucial, especially in patients with no prior abdominal surgery, to ensure early surgical intervention and reduced morbidity.

Transomental Hernia: Rare Presentation in a Virgin Abdomen

Internal hernias are characterized by the protrusion of abdominal viscera through congenital or acquired apertures within the abdominal cavity and are a recognized etiology of intestinal obstruction. Internal hernias can cause symptoms ranging from mild abdominal discomfort to complete intestinal obstruction. Transomental hernias are often associated with postoperative anatomical changes and are rare in patients without prior abdominal surgeries. This report details one case of a 31-year-old otherwise healthy female with no history of prior surgery, highlighting the clinical variability associated with internal hernias.  The patient presented with severe epigastric pain and nausea, with initial ultrasound findings unremarkable. Hours later, she returned with left iliac fossa pain and vomiting. A CT scan of the abdomen with contrast showed free fluid and dilated bowel loops, suggestive of small bowel obstruction. Emergency laparoscopy revealed small bowel herniation through a congenital omental band and ischemia, which resolved after the band was released. The patient recovered uneventfully and was discharged on day three. Transomental herniation exhibits nonspecific clinical symptoms of bowel obstruction. Radiographic presentations are generally nonspecific; however, a conclusive diagnosis is typically reached during surgery, where the detection of gangrenous bowel tissue is common, especially during exploratory laparoscopy. The postoperative mortality is largely attributed to bowel necrosis and delays in initiating treatment. This emphasizes the significant risk posed by undiagnosed cases and the critical importance of timely and effective intervention.

Spontaneous transomental hernia: a case report of a rare internal hernia with a challenging diagnosis

Introduction and Importance

Transomental hernia (TOH) is an extremely rare clinical condition that represents 1-4% of all internal hernias. Spontaneous TOH occurs in patients with no history of surgery or previous abdominal trauma. It happens after protrusion of the abdominal viscera, commonly the small bowel loops through a defect on the great omentum.

Presentation of the case

We present a case of occlusion due to TOH in a 66-year-old man who underwent a laparotomy, and operative exploration showed 10 cm of small bowel incarcerated through a defect in the right side of the greater omentum of 4 cm in diameter.

Discussion

The diagnosis is usually delayed because symptoms are nonspecific. Postoperative morbidity and mortality are important because patients present most frequently with gangrenous bowel, making morbidity and mortality higher. Therefore, it constitutes a critical surgical emergency and must be quickly recognized and managed. Computed tomography (CT) scan plays a prominent role in diagnosis. Midline laparotomy is the main emergency approach for patients with unknown bowel obstruction. Some authors suggest a laparoscopic approach, but it requires a surgeon's experience and propitious patient's conditions.

Conclusion

TOH is the rarest type of internal hernia with extremely difficult preoperative diagnosis due to nonspecific semiology. This type of hernia has the highest morbidity and mortality rates of all internal hernias. Thus, it must be suspected whenever there is bowel obstruction of unknown origin and quickly managed.

Radiographic Features of a Strangulated Transomental Hernia

This is a case report of an 82-year-old male who presented with intractable and diffuse abdominal pain and had a computed tomography (CT) abdomen showing a closed loop obstruction in the right hemiabdomen with anteromedial displacement of the cecum and ascending colon. Exploratory laparotomy revealed a gangrenous segment of the ileum strangulated by a transomental hernia in the right lower quadrant. The nonviable bowel was resected, and the healthy bowel segments were anastomosed. It is important to correlate the clinical signs of bowel obstruction with radiographic findings of internal hernia to expedite surgical intervention and prevent complications of bowel ischemia.

Laparoscopic surgery for two patients with strangulated transomental hernias

Background

Transomental hernias are a rare type of internal hernia. We report two cases of successful cases of laparoscopic repair. One required laparotomy due to concern for intestinal viability.

Case presentation

The first patient was a 67-year-old man who presented with abdominal pain and vomiting. He had no history of laparotomy or abdominal injury. Computed tomography suggested small bowel obstruction and possible intestinal strangulation. Emergent laparoscopy found approximately 200 cm of small bowel was strangulated around the greater omentum. The strangulation was released laparoscopically, but because of the color of the strangulated bowel, laparotomy was performed to evaluate viability. The involved portion of intestine was not resected. The patient experienced transient postoperative paralytic ileus and was discharged on postoperative day 14. The second patient was a 56-year-old man who presented with abdominal pain. Abdominal computed tomography revealed dilatation of the small intestine and a closed loop suggesting ileus due to intestinal strangulation. An emergency laparoscopy found a transomental hernia, and the strangulation was released laparoscopically. Recovery was uneventful, and the patient was discharged on postoperative day 6.

Conclusion

Transomental hernia can be successfully treated laparoscopically. In cases where bowel viability is a concern, laparotomy should not be hesitated.

Transomental hernia - An enigmatic case report causing bowel obstruction in a virgin abdomen

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Bowel obstruction happens to be the main presentation of most of the internal hernias.

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In its order of occourance transomental hernias are very uncommon and still are seen in present clinical practice mainly after bariatric surgery.

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We encountered a case of transomental hernia that caused subacute small bowel obstruction in a patient with no previous history of any abdominal operation, i.e. in a virgin abdomen.

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We would like to highlight the contribution of this case report to signify the presence of transomental hernias even in virgin abdomen unlike popular belief that it may occur in patients who may have undergone bariatric surgery, major liver surgery, etc.

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Whenever internal hernias are being considered as diagnosis the transomental hernias may also value consideration in a virgin abdomen.

Introduction

Transomental hernias are very uncommon form of internal hernias. Occasionally they may be seen in present clinical practice after bariatric surgery. Yet, this type of internal hernia remains mostly incidental and enigmatic in its presentation.

Clinical findings

We present a case of transomental hernia that caused subacute small bowel obstruction in a patient with no past history of any surgical procedure, i.e. in a virgin abdomen.

Diagnosis and therapeutic intervention

CT Scan of the abdomen revealed the presence of transomental hernia and it was addressed by laparoscopic surgery and an uneventful postoperative outcome.

Conclusion

Transomental Hernias can be present in virgin abdomen also. Its presence should be considered in all suspicions of internal hernia occurrence even though they are commonly known to be associated with bariatric surgery, liver surgery, etc.

Displacement of the transverse colon is a highly specific computed tomography finding for the preoperative diagnosis of a transomental hernia

PURPOSE

A transomental hernia (TOH) is a rare type of internal hernia and is associated with a high strangulation rate and high mortality rate. Displacement of the transverse colon on computed tomography (CT) may be specific to a TOH and may facilitate an early diagnosis. The aim of this study was to verify the effectiveness of a novel approach assessing displacement of the transverse colon for the preoperative diagnosis of a TOH.

MATERIALS AND METHODS

We retrospectively reviewed the CT and operative data of 113 patients who underwent surgery for small bowel obstruction (SBO) between 2011 and 2018. The proportion of transverse colon loops posterior to dilated intestinal loops (PTPI) was calculated.

RESULTS

The patients were divided into a TOH group (n = 7) and other SBO group (n = 106). The median PTPI was significantly higher in the TOH group than in the other SBO group (67% [0-97%] vs. 0% [0-100%], Wilcoxon's test, p = 0.03). A receiver operating characteristic curve showed that when the PTPI was ≥ 57%, its sensitivity and specificity for a TOH were 71% and 94%, respectively.

CONCLUSION

The PTPI is a reliable quantitative measure to distinguish a TOH from other types of SBOs.

Internal Hernia of the Greater Omentum: Cadaveric Findings of a Previously Unreported Variant

Transomental hernias (TOHs) are a rare finding, constituting a fraction of all intestinal hernias. Here, we report the cadaveric discovery of a spontaneous TOH involving the sigmoid colon in an 82-year-old female and discuss the relevant literature. To our knowledge, a TOH involving the sigmoid colon has not been previously reported.

Ischemic Strangulation of a Giant Epiploic Appendage through an Omental Defect: a Case Report

We report a rare case of an epiploic appendage twisted through an omental defect, resulting in an epiploic appendagitis at a distance to the colonic wall. The 59-year-old women complained of low abdominal pain and alguria, progressively increasing following a total colonoscopy 4 days earlier.

Spontaneous Transomental Hernia

A transomental hernia through the greater or lesser omentum is rare, accounting for approximately 4% of internal hernias. Transomental hernias are generally reported in patients aged over fifty. In such instances, acquired transomental hernias are usual, are commonly iatrogenic, and result from surgical interventions or from trauma or peritoneal inflammation. In rare cases, such as the one described in this study, internal hernias through the greater or lesser omentum occur spontaneously as the result of senile atrophy without history of surgery, trauma, or inflammation. A transomental hernia has a high postoperative mortality rate of 30%, and emergency diagnosis and treatment are critical. We report a case of a spontaneous transomental hernia of the small intestine causing intestinal obstruction. An internal hernia with strangulation of the small bowel in the lesser sac was suspected from the image study. After an emergency laparotomy, a transomental hernia was diagnosed.

A spontaneous transomental hernia through the greater omentum

Transomental hernia is the rarest form of internal hernias. Clinical expression of this pathology is ambiguous and diagnosis is often made at complication phase, after irreversible strangulation of the herniated loop. Radiological diagnosis is still difficult and intraoperative exploration usually allows discovering this pathology when patient is operated for acute intestinal obstruction. Treatment is surgical and aims to treat intestinal obstruction and prevent recurrence. We describe the case of a 65 years old male operated for a preoperatively suspected internal hernia; surgical exploration found a transomental hernia trough the greater omentum.