Internal hernia a preoperative diagnostic challenge in virgin abdomen: case report

Abstract

Internal hernias are classified in congenital or acquired. Congenital arises from abnormalities during embryonic development, whereas acquired result from trauma, surgical procedures, or another. Gastric surgical procedures can increase susceptibility to internal hernias. A 85-year-old female, denies previous surgeries. Went to the emergency department due to vomiting, adding colicky abdominal pain. Was discharged with a diagnosis of acute gastroenteritis. Came back 12 hours after discharge due to mesogastric pain accompanied by general malaise, abdominal distention and hyporexia, reporting a lack of evacuation. She was algid, pale, abdomen globose, distended, tympanic colonic frame, peristalsis increased. An evaluation was requested from general surgery for probable appendicitis in the elderly vs. secondary ileus. Went to operation room, finding an internal hernia. Transomental herniations are rare conditions. An abnormal omental opening can be either acquired following abdominal surgery, trauma, inflammatory conditions, low body mass index (BMI) and be associated with a long mesentery, intestinal malrotation, or abnormal peritoneal attachments. Although internal hernias are extremely rare (between 1 and 4% of acute or intermittent intestinal obstructions) it is essential not to miss this diagnosis, even in patient whit no previous surgeries. Management of omental hernias are critical as the postoperative mortality rate is over 30% and even 50% if strangulation is present. The lack of current literature on this rare condition, particularly for lesser omental hernias (because can present with nonspecific signs and symptoms) makes diagnosis and management difficult.