’The ins and outs of abdominal pain’: a case report of a transomental internal hernia

Abstract

A 46-year-old man was admitted via the emergency department with sudden onset, left-sided, sharp, abdominal pain that had awoken him from sleep. Two days previously, he had a similar episode of abdominal pain that resolved upon bowel opening. He had no other symptoms and had an unremarkable past medical history. On examination, he was distressed and in pain, but had a soft, non-distended abdomen. There was mild tenderness in the left iliac fossa on deep palpation, but nothing else of note. The bowel sounds were normal. Besides a minor leucocytosis, all preliminary investigations, including arterial blood gases, were reported normal. He remained haemodynamically stable throughout. However, his pain was significantly out of proportion to the clinical findings and the results of initial investigations. An unenhanced computed tomography (CT) scan of the abdomen was performed (Fig. 1). DiscussionFigure 1 is a composite image of a series of unenhanced CT sections in a craniocaudal direction. They demonstrate a distend loop of small bowel in a 'C' shape lying under the left anterior abdominal wall (image 5). The mesenteric vessels leading to this loop can be seen to be converging. There is loss of sharpness of these vessels with haziness of the fatty tissue surrounding them (images 1-4). The convergence of the vessels infers the presence of a defect through which this loop has herniated creating a 'closed loop' obstruction and the haziness is indicative of vascular compromise.Investigative laparoscopy revealed, blood-stained fluid with multiple distended loops of small bowel. At exploratory laparotomy (Fig. 2), a congested, but viable, ileal loop was found, herniating through the greater omentum. The herniation was released and the omental defect and abdomen closed. The patient was discharged 2 days later.Internal hernias have an autopsy incidence of 0.2-0.9%. 1Transomental (greater or lesser) are rarer still accounting for less than 1% of all internal hernias and are usually a complication of previous surgical procedures. [2][3][4] Small bowel obstruction secondary to an internal hernia is a surgical emergency. Whilst abdominal radiographs and ultrasonography may be of some diagnostic use, CT scanning remains the gold standard. 3,5 ConclusionsThis case promotes the consideration and early recognition of internal herniae as a cause of abdominal pain in patients presenting to the emergency department. Despite the rarity We present the case of a 46-year-old man admitted with acute abdominal pain with no obvious cause despite simple investigations. Further imaging revealed a rare transomental internal hernia. At exploratory laparotomy, the hernia was released, no bowel resection was required and the patient was discharged 2 days later. ON-LINE CASE REPORT

Case report of a lesser sac intestinal herniation through a defect in the gastro-hepatic omentum and novel repair technique using biological glue

“…Several anatomical findings have been linked to the development of primary LSH, which include wide epiploic foramen, hypogenic transverse mesocolon, diminutive greater omentum, and long small intestinal mesentery [8,9]. The reduced fat content of omental ligaments has been suggested as a possible factor in the developing of omental hernial defects [10].…”

Strangulated transomental hernia: case report and literature review

“…8 The clinical presentation corresponds to an acute occlusive syndrome, generally non-specific, which is the case in our patient.The abdominal CT scan with contrast can confirm the diagnosis preoperatively by showing the passage of mesenteric vessels through the epiploic defect, except that only 8% of transomental hernias would be diagnosed preoperatively. 9 The laparoscopic approach has a diagnostic and therapeutic purpose, in cases where the defect is anterior and easy to identify and can be repaired without any particular technical difficulty, but median laparotomy should be preferred as a first-line procedure in the event of a intolerable occlusive syndrome 10 bowel reduction can usually be done by simple traction, but this can be made difficult by acquired adhesions, hence the interest in enlarging the defect. In case of intestinal necrosis, resection of the necrotic segment is necessary.…”

Internal transomental herniation with a trapped small bowel mimicking acute appendicitis

“…A transomental herniation with no previous abdominal surgery is extremely rare, with roughly 50 cases reported to date. 2,3 Various causes of omental defect have been discussed in the literature, such as trauma, inflammation, congenital defects or age-related atrophy. Nevertheless, the causes of omental defects remain unclear in most cases.…”