Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2007  |  Volume : 13  |  Issue : 3  |  Page : 141-143
Mesocolic hernia: An unusual internal hernia


Department of Surgery, Father Muller Medical College Hospital, Kankanady, Mangalore - 575 002, Karnataka, India

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Date of Submission20-Apr-2007
Date of Acceptance01-Jun-2007
 

   Abstract 

Internal hernia may be either congenital or acquired. Its incidence has been reported to be 1-2%. Herniation may be persistent or intermittent. Internal hernia is a rare cause of small bowel obstruction with a reported incidence of 0.2-0.9%. The most common type is paraduodenal. Less common types include mesocolic hernia, which occurs following abdominal surgery. We report mesocolic hernias in two young patients, which presented as small bowel obstruction without any prior abdominal surgery.

Keywords: Mesocolic hernia, internal hernia, intestinal obstruction

How to cite this article:
Tauro L F, Vijaya G, D'Souza C, Ramesh H C, Shetty S R, Hegde B R, Deepak J. Mesocolic hernia: An unusual internal hernia. Saudi J Gastroenterol 2007;13:141-3

How to cite this URL:
Tauro L F, Vijaya G, D'Souza C, Ramesh H C, Shetty S R, Hegde B R, Deepak J. Mesocolic hernia: An unusual internal hernia. Saudi J Gastroenterol [serial online] 2007 [cited 2019 Aug 18];13:141-3. Available from: http://www.saudijgastro.com/text.asp?2007/13/3/141/33468


Internal hernia is a rare cause of intestinal obstruction and is difficult to diagnose preoperatively. [1],[2],[3],[4] The most common type of internal hernia is paraduodenal. Less common types include mesocolic (transmesenteric) hernia, which occurs following abdominal surgery. [5],[6] We report mesocolic hernia in two young patients, which presented as small bowel obstruction without any prior abdominal surgery.


   Case Reports Top


Case 1

A 19 year-old female patient was admitted with abdominal pain and vomiting of three days' duration. Prior to this episode, she was normal and there was no past history of any abdominal surgery. On general physical examination, the patient was found to be febrile, tachycardiac and tachypnoeic. Abdominal examination revealed distention, diffused tenderness and rebound tenderness in the umbilical region and the right iliac fossa. Shifting dullness and fluid thrill was present. Bowel sounds were sluggish.

Her total and differential leukocyte counts revealed leukocytosis and neutrophilia respectively. Blood group was B negative. Plain abdominal X-ray revealed dilated small bowel loops in the upper abdomen [Figure - 1]. Abdominal ultrasonography revealed dilated, fluid-filled and edematous small bowel loops suggestive of intestinal obstruction with significant ascitis. Abdominal computed tomography (CT) scan showed a segment of dilated ileum with features of strangulation.

Explorative laparotomy through right paramedian incision revealed hemorrhagic peritoneal fluid with internal herniation of the terminal ileum and caecum into the supra-colic compartment through a defect in the transverse mesocolon on the right side. Transverse colon was displaced dorsally, ascending colon medially. A length of the terminal ileum spanning 35 cm was found to be gangrenous and proximal ileum and jejunum was dilated [Figure - 2]. There were no malrotation abnormalities. The constricting ring of the defect was incised and herniation was reduced [Figure - 3].

The gangrenous segment of the ileum with caecum was resected and end-to-end ileo-ascending colon anastomosis was performed. The defect in the transverse mesocolon was closed using 2-0 silk. After a thorough peritoneal lavage, the abdomen was closed in layers after placing a drain in the pelvis. Two units of blood were transfused postoperatively. The drain was removed on the 4 th postoperative day and sutures were removed on the 10 th postoperative day. Histopathological examination of the resected specimen revealed a gangrenous terminal ileum. The postoperative period was uneventful and after six months' follow-up, the patient is still asymptomatic.

Case 2

A 25 year-old male patient was admitted with a history of abdominal pain and vomiting of two days' duration. The patient had recurrent attacks of abdominal pain in the past, which used to subside with medical treatment. He had no history of prior abdominal surgery. On general physical examination, the patient was found to have tachycardia. Abdominal examination revealed distention, tenderness all over the abdomen with loud bowel sounds. Plain abdominal X-ray revealed multiple air fluid levels suggestive of intestinal obstruction.

Abdominal ultrasound revealed dilated fluid-filled loops of small bowel with minimal ascitis. Hematological and biochemical investigations were within normal limits. Explorative laparotomy revealed internal herniation of ileal loops through a defect in the transverse mesocolon on the right side, without any strangulation of the small bowel. The contents were reduced and the defect in the transverse mesocolon was closed. The postoperative period was uneventful and after two years of follow-up, the patient is still asymptomatic.


   Discussion Top


Internal hernias are defined as herniation of a viscus, usually the small bowel, through a normal or abnormal aperture within the peritoneal cavity. These hernias may be either congenital or acquired. Its incidence has been reported to be 1-2%. [1],[2],[5] This herniation may be persistent or intermittent. Internal hernia is a rare cause of small bowel obstruction [1],[2],[3],[4] with a reported incidence of 0.2-0.9%. [2],[3],[4],[5] Due to the risk of strangulation of the hernial contents, even small internal hernias are dangerous and may be lethal. More than 50% of internal hernias reported in the literature are paraduodenal. [2],[3],[4],[5]

The other types of internal hernias that have been described include mesocolic (transmesenteric), supra- and / or perivesical, intersigmoid, foramen of Winslow and rarely, omental hernias. [3],[4],[5] The orifice of the internal hernia may be normal (Winslow's foramen) or abnormal (paraduodenal, ileocaecal etc.) or pathological (orifice formed in a mesentery or omentum) or anomalous. [2],[7]

Mesocolic / transmesenteric hernias occur through iatrogenically created defects in the mesentery. These defects include herniation of an abdominal viscus, usually through the small bowel mesentery or transverse mesocolon. These hernias are common following abdominal surgery, especially Roux-en-Y loop reconstruction, [5],[6],[8] which creates a defect in the mesentery. When the small bowel is herniated through a defect in the mesentery or omentum, the herniated bowel is compressed against the abdominal wall.

There is no overlying omental fat in most cases and at most levels of anatomic sections, through the herniated bowel. The herniated bowel tends to appear clustered and lies outside the colon, a reversal of the normal anatomic arrangement. As a result, the adjacent colon is displaced centrally ( e.g ., transverse colon displayed dorsally, ascending colon displaced medially) There will be some degree of compression, crowding, displacement and obstruction of both the bowel and blood vessels. The herniated bowel may also twist within the hernial sac, which results in volvulus and a predisposition to bowel ischemia.

Twisting of the mesenteric vessels or the whirl sign or twisting of the bowel itself is diagnostic of volvulus. Engorged blood vessels, mesenteric ascitis and bowel wall thickening suggest bowel ischemia. [5] Internal hernias are difficult to diagnose preoperatively by physical examination, therefore, imaging is relied upon for preoperative diagnosis. Since herniation is often intermittent, the radiographic diagnosis depends on the time of imaging. Plain film radiographic findings are usually nonspecific (normal, partial or complete bowel obstruction); yet upper gastro-intestinal small bowel follow-through, CT scan and occasionally ultrasound may facilitate the diagnosis of identifying isolated bowel-"a bag of bowel" in the hernial sac. [2],[5],[8] The most important diagnostic tool is CT, which is accurate in 77% [9] of the cases.

Barium studies and CT examination of these hernias may also show the point of transition where the bowel loops enter or exit the orifice. Angiography reveals an altered course of jejunal vessels as they course along the herniated portion of the bowel. [2],[5] Treatment consists of reduction of hernia by gentle traction and closure of the defect with care not to injure the vessels near the hernial sac margin. [1],[2] In the case of internal hernias, the best course is to correct the defects in the mesentery and the abnormalities of malrotation when incidentally noted. Right mesocolic hernia is repaired by moving the colon to the left after dividing the peritoneal attachments and leaving the small bowel on the right.

Left mesocolic hernia is treated by making an incision where the encapsulated hernial sac fuses with the left mesocolon to release the trapped bowel. [2] Both of our patients had right-sided mesocolic hernias. These patients did not have any prior abdominal surgery. In both the cases, the hernial orifice may have been a congenital defect (anomalous orifice) in the transverse mesocolon. There were no abnormalities of malrotation noted in these cases. Internal hernias, while uncommon, represent an important and under-diagnosed condition. A high index of suspicion with prompt surgical intervention may be the key to the reduction of morbidity and mortality in such patients.

 
   References Top

1.Yokota T, Yamada Y, Murakami Y, Yasuda M, Teshima S, Kunii Y, et al . Emergency abdominal surgery for sigmoid mesocolic hernia. Am J Emerg Med 2002;20:137-8.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Munir A, Saleem SM, Hussain S. Paraduodenal hernia: A case report. J Pak Med Assoc 2004;54:162-3.  Back to cited text no. 2  [PUBMED]  
3.Li JC, Chu DW, Lee DW, Chan AC. Small-bowel intestinal obstruction caused by an unusual internal hernia. Asian J Sung 2005;28:62-4.  Back to cited text no. 3    
4.Kulacoglu H, Tumer H, Aktimur R, Kusdemir A. Internal herniation with fatal outcome: Herniation through an unusual aperture between epiploic appendices and greater omentum. Acta Chir Belg 2006;106:109-11.  Back to cited text no. 4  [PUBMED]  
5.Blachar A, Federle MP, Dodson SF. Internal hernia: Clinical and Imaging Findings in 17 patients with Emphasis on CT criteria. Radiology 2001;218:68-74.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Halpenny J. Internal hernia: With a report of a case of Mesocolic Hernia. Can Med Assoc J 1912;2:1094-8.  Back to cited text no. 6    
7.Brehm V, Smithuis R, Doornebosch PG. A left paraduodenal hernia causing acute bowel obstruction: A case report. Acta Chir Belg 2006;106:436-7.  Back to cited text no. 7  [PUBMED]  
8.Janin Y, Stone AM, Wise L. Mesenteric hernia. Surg Gynaecol Obstet 1980;150:747-54.  Back to cited text no. 8    
9.Mecussen C, Huyghe M, Deckers K. Paraduodenal hernia evoking intermittent abdominal pain. Acta Chir Belg 2006;106:211-4.  Back to cited text no. 9    

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Correspondence Address:
L F Tauro
Department of Surgery, Father Muller Medical College Hospital, Kankanady, Mangalore - 575 002, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.33468

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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]

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