The occurrence of a strangulated ileus due to a traumatic transmesenteric hernia: report of a case

Strangulation of the small intestine caused by an intra-mesosigmoid hernia: a case report

Sigmoid mesocolon hernia is an uncommon type of internal hernia with only a few cases reported to date. This disease entity can progress rapidly to cause vascular disturbance, necrosis, and perforation of the bowel wall; therefore, early diagnosis and surgical treatment are essential. We describe the case of an intra-mesosigmoid hernia in a 60-year-old man without history of previous abdominal surgery who presented with sudden acute abdominal pain and vomiting. Based on computed tomography, which showed ascites and small bowel obstruction, we diagnosed him as having strangulation of the small intestine caused by a sigmoid mesocolic hernia and performed emergency surgery. Laparotomy revealed small intestinal strangulation, extensive engorgement, and discoloration of bowel loops. Approximately 100 cm of the small intestine extending from the ligament of Treitz had undergone strangulation and herniated into the defect of sigmoid mesocolon, leading to a diagnosis of an intra-mesosigmoid hernia. Because the incarcerated portion of the small intestine was viable, we did not perform intestinal resection and reconstruction but closed the defect in the sigmoid mesocolon. His postoperative course was uneventful.

[L-lactate as a serum marker of intestinal ischemia in patients with complicated intestinal obstruction]

BACKGROUND

The intestinal obstruction secondary to internal hernia is a diagnostic challenge. The absence of specific symptoms and signs during clinical examination often lead to underestimation of the severity and early surgical treatment. The purpose of this article is to review the clinical presentation of two patients with internal hernia, describe the clinical, biochemical and radiological findings, with emphasis on the L-lactate as an early serum marker of intestinal ischemia.

CLINICAL CASES

Case 1: female, 44 years history of urolithiasis and 2 cesarean sections. Case 2: female, 86 year old with a history of open cholecystectomy, incisional and bilateral inguinal hernia repair with mesh placement. Both admitted with abdominal pain and intestinal obstruction data. The only significant laboratory finding was elevation of L-lactate. The abdominal films showed air-fluid levels, dilated loops of small intestine and colon. Abdominal contrast tomography showed free abdominal fluid id, internal hernia and torque of mesentery. In both cases, exploratory laparotomy was performed with bowel resection of ischemic segments, with uneventful recovery.

CONCLUSIONS

Intestinal ischemia secondary to internal hernia is difficult lt to diagnose. In patients with a high suspicion, signs of intestinal obstruction by plain radiography, the elevation of L-lactate, could help in the early diagnosis of intestinal ischemia and immediate surgical treatment.

Laparoscopic Repair of Internal Transmesocolic Hernia of Transverse Colon

Introduction. Internal hernias are often misdiagnosed because of their rarity, with subsequent significant morbidity. Case Presentation. A 61-year-old Japanese man with no history of surgery was referred for intermittent abdominal pain. CT suggested the presence of a transmesocolic internal hernia. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We found internal herniation of the small intestine loop through a defect in the transverse mesocolon, without any strangulation of the small intestine. We were able to complete the operation laparoscopically. The patient's postoperative course was uneventful and the patient was discharged on postoperative day 6. Discussion. Transmesocolic hernia of the transverse colon is very rare. Transmesocolic hernia of the sigmoid colon accounts for 60% of all other mesocolic hernias. Paraduodenal hernias are difficult to distinguish from internal mesocolic transverse hernias. We can rule out paraduodenal hernias with CT. Conclusion. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We report a case of a transmesocolic hernia of the transverse colon with intestinal obstruction that was diagnosed preoperatively and for which laparoscopic surgery was performed.

Left-sided transmesocolic herniation of small bowel in an otherwise unaffected abdomen

Transmesocolic hernia is an uncommon type of internal hernia with incidence ranging from approximately 5-10%. To the best of our knowledge, this is the first reported case of a transmesocolic hernia through a gap within the descending mesocolon presenting clinically as an intestinal obstruction. A 75-year-old man was admitted with clinical features of intestinal obstruction. An abdominal X-ray showed multiple small bowel loops with air fluid levels. Contrast-enhanced CT of the abdomen revealed small bowel obstruction not only on the right, but also on the left side of the collapsed descending colon. Emergency surgery was performed. Strangulated bowel loops with gangrenous changes were resected and double-barrel ileostomy was carried out. The postoperative period was uneventful. Restoration of bowel was performed after 6 weeks. Preoperative diagnosis of bowel obstruction caused by a transmesocolic hernia remains difficult despite the currently available imaging techniques. Prompt surgery can prevent serious complications such as peritonitis and sepsis.

Strangulated small bowel obstruction secondary to a transmesosigmoid hernia

Internal hernias are an infrequent cause of small bowel obstruction with transmesosigmoid herniation being very rare, especially in patients with no history of abdominal surgery or trauma. Early surgical intervention is important in acute presentation to reduce the high morbidity and mortality rates associated with this disease.

Transmesocolic hernia of the ascending colon with intestinal obstruction

An internal hernia may be either congenital or acquired. The reported incidence of such hernias is 1–2%. In rare cases, internal hernias are the cause of small bowel obstruction, with a reported incidence of 0.2–0.9%. Transmesocolic hernia of the ascending colon is especially rare. We report a case of transmesocolic hernia of the ascending colon with intestinal obstruction diagnosed preoperatively. A 91-year-old Japanese female was admitted to our hospital with abdominal distention and vomiting of 3 days duration. She had no past history of any abdominal surgery. Abdominal examination revealed distention and tenderness in the right iliac fossa. Abdominal computed tomography revealed ileus in the sac at the left side of the ascending colon and dilatation of the oral side of the intestine. We diagnosed a transmesocolic hernia of the ascending colon with intestinal obstruction and performed emergency surgery. At the time of operation, there was internal herniation of ileal loops through a defect in the ascending mesocolon, without any strangulation of the small bowel. The contents were reduced and the tear in the ascending mesocolon was closed. The postoperative course was uneventful and the patient was discharged 14 days after surgery. In conclusion, preoperative diagnosis of bowel obstruction caused by a congenital mesocolic hernia remains difficult despite the techniques currently available, so it is important to consider the possibility of a transmesocolic hernia when diagnosing a patient with ileus with no past history of abdominal surgery.

Congenital transmesenteric defect causing bowel strangulation in an adult

INTRODUCTION

Congenital transmesenteric hernias represent a very small group of internal hernias which are uncommon and are a rare cause of intestinal obstruction. Diagnosis is frequently made at surgery. Reports of congenital transmesenteric hernia in the English literature usually involve the pediatric population; adult cases are rarer.

CASE REPORT

A 22-year-old man who presented with a day's history of severe abdominal pain but without classic physical examination signs of abdominal obstruction was operated upon on account of increasing abdominal pain and distention associated with shock. Laparotomy revealed a congenital transmesenteric defect through which loops of bowel had herniated and become gangrenous, resulting in resection and end-to-end anastomosis.

DISCUSSION

Congenital transmesenteric defects causing internal hernias in adults are rare. Preoperative diagnosis of the condition is difficult, in part, because there are no radiographic or laboratory findings to confirm the suspicion. Misdiagnosis resulting in delayed exploration may lead to small bowel necrosis and subsequent mortality.

CONCLUSION

A congenital internal hernia should be considered in a patient with bowel obstruction without previous abdominal surgery, inflammatory abdominal condition, or trauma. We wish to emphasize that, rather than trying to establish a correct diagnosis, the patient's clinical features should lead to early surgery in order to reduce morbidity and possible mortality.

Incarcerated transmesosigmoid hernia presenting in a 60-year-old man: a case report

INTRODUCTION

Internal hernias are a rare cause of small bowel obstruction and are estimated to account for 1% to 5% of cases. Herniation through a defect in the sigmoid mesocolon constitutes 6% of all internal hernias.

CASE PRESENTATION

In this case report we describe a rare case of a fit and healthy 60-year-old man, with no previous history of abdominal surgery, who presented with signs and symptoms of small bowel obstruction as a result of an incarcerated transmesosigmoid hernia. The hernia was reduced and the incarcerated loop of small bowel was found to be viable. The patient made a good recovery and was discharged home on the fourth post-operative day.

CONCLUSION

Internal hernias can cause considerable morbidity and mortality, so prompt diagnosis is paramount. Transmesosigmoid hernias are most common in the paediatric population; however, our patient was 60 years old. This report highlights the importance of considering an internal hernia as a cause of small bowel obstruction in individuals of all age groups and especially in those without a previous history of abdominal surgery.

Asynchronous Small Bowel Obstruction: A Complication of Blunt Abdominal Trauma

A 38-year-old male who sustained blunt abdominal trauma at work presented to the emergency department with complaints of abdominal pain localized primarily in the peri-umbilical region. The patient was discharged home after a brief uneventful hospitalization only to return 13 days later with signs and symptoms of acute bowel obstruction. Following clinical and radiological workup, a computed tomography (CT) scan was obtained which revealed markedly dilated and thickened bowel, induration and vascular congestion seen along the adjacent mesentery with fat stranding. The patient was taken emergently to the operating room (OR) where a small mesenteric defect was found, secondary to trauma, facilitating an internal hernia precipitating a small bowel obstruction. We urge the surgeon to maintain a low index of suspicion for acute bowel obstruction in the blunt trauma population. A CT scan is essential in evaluating this patient population and we cannot underscore enough the importance and value of this modality in radiologic imaging. We further recommend resection of the compromised bowel and associated mesentery.