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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00970-2
10.1016/j.ijscr.2024.110189
110189
Case Report
Congenital transmesenteric hernia: A rare case in adults
de Jesús González-Luna Antonio a
Álvarez-Gutierrez Jaime Antonio a
Cruz-Bonilla Natalia a
Juárez-Mora Matthew Abel b
Torres-Salazar Quitzia Libertad quitzia.torres@gmail.com
c⁎
a Regional Hospital “Dr. Valentín Gómez Farías”, Institute of Security and Social Services for State Workers, Mexico
b Autonomous University of Guadalajara, Mexico
c Juárez University of the State of Durango, Mexico
⁎ Corresponding author at: “Alpha 0.01” Biomedical Research Institute, Paloma 812, Colonia Fátima Durango, Dgo. C.P. 34060, Mexico. quitzia.torres@gmail.com
22 8 2024
10 2024
22 8 2024
123 11018923 7 2024
13 8 2024
15 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Congenital transmesenteric hernia is a rare form of hernia and intestinal obstruction. Autopsy studies report an incidence of 0.2–0.9 % of internal hernias, causing intestinal obstruction in 4.1 % of all cases.

Case presentation

A 35-year-old female patient, with no surgical history, presented with severe abdominal pain in the right hemiabdomen, nausea, and vomiting. She was initially unsuccessfully treated for gastritis. Upon admission to our unit, she had stable vital signs but severe abdominal pain. An acute abdomen was diagnosed, and a diagnostic laparoscopy converted to open surgery revealed an internal transmesenteric hernia with partial intestinal obstruction. A right hemicolectomy with ileotransverse anastomosis was performed.

Clinical discussion

Diagnosing this condition is challenging due to nonspecific symptoms and signs, and radiological investigations may not provide sufficient information. The clinical features of a transmesenteric hernia can mimic more common causes of acute abdominal pain, such as appendicitis, complicating early identification. Computed tomography (CT) is the most useful imaging modality, but even with CT, the diagnosis can be difficult due to the rarity of the condition and the lack of specific signs.

Conclusion

Early intervention and surgical correction in this case were crucial to preventing mortality associated with internal hernias.

Evidence based medicine ranking

Level IV.

Highlights

• Congenital transmesenteric hernia is a rare cause of intestinal obstruction.

• Symptoms include severe abdominal pain, nausea, and vomiting.

• Diagnosis is challenging due to the nonspecific nature of the symptoms.

• Early surgical intervention is crucial to prevent mortality.

Keywords

Transmesenteric hernia
Congenital
Internal hernias
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pmc1 Introduction

An internal hernia is defined as the protrusion of intestines or other abdominal organs through a mesenteric or peritoneal recess, which can occasionally lead to serious complications such as strangulation or incarceration [1]. While internal hernias are a rare cause of intestinal obstruction, their clinical significance lies in their potential to cause life-threatening conditions if not promptly diagnosed and treated. Autopsy studies report an incidence of internal hernias in 0.2–0.9 % of the population, with these hernias responsible for 4.1 % of all cases of intestinal obstruction [2]. Internal hernias can be either congenital or acquired. Congenital internal abdominal hernias (CIAH) result from anomalies during embryonic development, while acquired internal hernias may arise from trauma, previous surgical procedures, or other pathological conditions. Certain surgical interventions, particularly those involving the stomach, such as Roux-en-Y gastric bypass, choledochojejunostomy, and gastrectomy, are known to increase the risk of developing internal hernias [3].

The topographical classification by Welch and collaborators categorizes internal hernias into eight groups based on their anatomical location, which is crucial for understanding and diagnosing these conditions in clinical practice [4]. Among these, an internal mesenteric hernia is an exceedingly rare type where a portion of the intestine herniates through a defect in the mesentery, the tissue that anchors the intestines to the abdominal wall. This type of hernia occurs within the abdominal cavity and can lead to intestinal obstruction, a medical emergency that poses a high risk of ischemia and necrosis of the affected bowel if not promptly addressed [5]. Clinical symptoms include acute abdominal pain, nausea, vomiting, abdominal distension, and difficulty passing gas or stools [6].

In the context of CIAH, hernias can be divided into those that are retroperitoneal and those that originate from congenital abnormal openings. Retroperitoneal hernias include paraduodenal, foramen of Winslow, paracecal, and intersigmoid hernias, while hernias related to congenital abnormal openings include transmesenteric, broad ligament, and transomental hernias [7]. Among these, transmesenteric hernias (TMH) are the most common in children, primarily due to defects in the mesentery of the small intestine. Although CIAH is frequently reported in pediatric populations, it is rare in adults, making cases in this group particularly noteworthy [4].

Given the rarity and potential severity of transmesenteric hernias in adults, we present the clinical case of a 35-year-old woman diagnosed with congenital transmesenteric hernia. This case underscores the importance of considering internal hernias in the differential diagnosis of intestinal obstruction, even in adult patients, and highlights the critical need for timely intervention to prevent severe complications. This report follows the SCARE criteria [8].

2 Clinical case presentation

We present the case of a 35-year-old female patient from Guadalajara, residing in Zapopan, who worked as a nurse. The patient had a history of tonsillectomy 13 years ago, two uncomplicated deliveries, and no history of previous abdominal surgery. She reported allergies to ciprofloxacin, cephalexin, indomethacin, and caffeine. Her clinical presentation began with abdominal pain localized in the right hemiabdomen, described as intermittent dull pain that later intensified to severe pain (10/10 on the VAS scale), accompanied by nausea and vomiting (4 episodes). She visited the emergency room at another hospital 24 h later, where she was initially treated with omeprazole, NSAIDs, and antispasmodics for gastritis, but without improvement. She was subsequently evaluated at another center with imaging studies (abdominal X-ray) and sent home again without any initial treatment modification (Fig. 1). The radiographic images revealed significantly distended segments of the small intestine, raising suspicion for a possible “closed loop” obstruction. Clusters of dilated, overlapping small bowel loops were identified, situated in an abnormal location. Additionally, multiple air-fluid levels were visualized, which may suggest an intestinal obstruction. The patient's condition continued to deteriorate over the next 7 days, despite the lack of improvement. After experiencing more than 15 episodes of vomiting and persistent, severe abdominal pain (rated 10/10 on the VAS scale), the patient presented to our hospital.Fig. 1 Pre-surgical X-ray in standing position.

Fig. 1

Upon physical examination at admission, the patient's vital signs were as follows: blood pressure 106/70 mmHg, heart rate 105 bpm, respiratory rate 22 breaths/min, oxygen saturation 96 %, and temperature 36.9 °C. The patient was alert and oriented, with a Glasgow Coma Scale score of 15. Chest examination revealed vesicular breath sounds. Initial laboratory results indicated a urinary tract infection, with urinalysis showing 25 leukocytes per field, positive erythrocytes, and ketones. Given the clinical presentation—characterized by severe abdominal pain, a positive rebound sign, acute abdomen, and hydro-aerial levels on abdominal X-ray—we proceeded with an exploratory laparoscopy as a diagnostic alternative due to the unavailability of a CT scan. Within 24 h of admission, the patient's blood chemistry, liver function tests, and serum electrolytes were within normal limits, except for slightly low sodium levels. The complete blood count showed leukocytosis at the upper limit of normal. The patient was admitted with a diagnosis of acute abdomen and underwent diagnostic laparoscopy.

2.1 Surgical technique

With informed and signed consent, the patient was transferred to the operating room. After abdominal asepsis and antisepsis, sterile drapes were placed. A transverse infraumbilical incision was made, dissecting through layers until reaching the aponeurosis using the Hasson technique. Pneumoperitoneum was initiated with CO2 up to 12 mmHg, and a 12 mm trocar was placed. The laparoscope was introduced, and a systematic review of the puncture site and abdominal cavity was performed, revealing inflammatory fluid in the pelvic cavity.

A 12 mm trocar was placed in the left iliac fossa and a 5 mm suprapubic trocar. Abundant free inflammatory fluid was identified, and after a systematic review of the cavity, two perforations were observed. Conversion to open surgery was decided. Upon inspection, a segment of the ileum without mesentery was found, rotated on its own axis (Fig. 2). Terminal ileum resection (approximately 40 cm) was performed, encompassing the internal hernia and perforations (Fig. 3).Fig. 2 Segment of small intestine (ileum) showing an intestine without mesentery in a patient with no previous surgical procedures.

Fig. 2

Fig. 3 Resection of an intestinal segment showing the ileum and its junction with the cecum and large intestine following right hemicolectomy, with a segment lacking mesentery.

Fig. 3

The Toldt fascia was dissected, freeing the colon from the cecum to the hepatic flexure cephalically with harmonic Enseal support until the hepatic flexure was freed. The proximal colon was closed with continuous Vycril 00, reinforced with Lembert stitches. An ileostomy was created, and a manual end-to-side anastomosis was performed with Connell and Mayo stitches, reinforced with continuous sutures. The gap was closed with Vycril 2–0.

The cavity was irrigated with warm saline solution and aspirated. Hemostasis was achieved. The count of textiles and instruments was complete. A Jackson-Pratt drain was placed in the pelvic cavity and exteriorized through the 5 mm port. The aponeurosis of the right 10 mm port was closed with Vycril 1, and the midline aponeurosis was closed with continuous Vycril 1. Subcutaneous tissue was closed with Vycril 2–0, and the skin with simple nylon 2–0 stitches. The surgical procedure was completed, and the patient was transferred to recovery.

The final diagnosis of the previous procedure was internal transmesenteric hernia with partial intestinal obstruction, requiring diagnostic laparoscopy converted to right hemicolectomy with manual ileotransverse anastomosis and primary closure of small intestine perforation. The specimen was sent for histopathological study, which reported sections of mucosa showing glandular epithelial hyperplasia, mild fibrosis with stromal edema, and severe multifocal lymphoid hyperplasia with a follicular pattern. No signs of neoplasia were observed in the analyzed specimen.

In the first hours of postoperative surveillance, the patient reported abdominal pain 5/10 on the VAS scale, adequately tolerated, and was mobilizing in bed. Within 48 h post-surgery, the patient remained with a nasogastric tube with the last reported output of 200 cc, Jackson drain without reported outputs, and urinary catheter. The surgical wound appeared well-approximated, without signs of dehiscence or infection. The patient was discharged after 72 h of observation, during which they remained stable and free of complications. Follow-up evaluations at one week and one month post-discharge indicated good progress.

3 Discussion

Preoperative diagnosis of an internal hernia is complicated due to the nonspecific presentation of symptoms, including acute abdominal pain, nausea, vomiting, and abdominal distension. Computed tomography (CT) studies can provide diagnostic suspicion by revealing small bowel dilatation, clumping of small bowel loops, central displacement of the colon, and absence of omental fat over the clump. However, the sensitivity and specificity of CT for diagnosing transmesenteric hernias are estimated at 63 % and 76 %, respectively [9]. Mesenteric vessel congestion observed in approximately 79–84 % of cases may be a useful indicator, but these findings can be difficult to distinguish from other internal hernias, often delaying definitive diagnosis until surgical exploration [10]. In the case we presented, unfortunately, it was impossible to use CT as a diagnostic tool due to administrative issues. Waiting for a CT scan in the context of suspected acute abdomen would have increased the likelihood of complications. Therefore, we opted for diagnostic laparoscopy to promptly identify the underlying pathology and proceed with the necessary surgical intervention.

The presented case of a 35-year-old woman highlights the importance of considering internal hernias in the differential diagnosis of acute intestinal obstruction, especially in patients without previous surgical history. Early surgical intervention is crucial, as delayed treatment can lead to severe complications such as intestinal gangrene, increasing resection rates and mortality [11]. Songadkar SV et al. reported a case of a 22-year-old adult with a distal ileal transmesenteric hernia through a congenital ileal mesenteric defect, resulting in closed-loop intestinal obstruction and distal ileal gangrene, managed with resection and terminal ileostomy, followed by stoma reversal a month later [11]. In the case presented here, the patient underwent diagnostic laparoscopy converted to open surgery, with terminal ileum resection and ileotransverse anastomosis due to the identification of an ileum without mesentery rotated on its axis.

Reviewed literature indicates that congenital internal hernias are more prevalent in the pediatric population, where diagnosis is also critical due to the inherent risk of complications [12]. However, their occurrence in adults, although infrequent, should be seriously considered by healthcare professionals. This recognition is crucial to prevent severe complications and improve outcomes in affected patients. Previous studies have shown that most cases of congenital internal hernias are reported as individual cases rather than case series, emphasizing the need for a high index of clinical suspicion and timely surgical intervention. Early and accurate intervention is essential to mitigate the risks of morbidity and mortality associated with this condition. In this regard, Wu et al. emphasize that rather than attempting to establish a precise preoperative diagnosis, the patient's clinical features should guide early surgery to reduce morbidity and potential mortality. This recommendation highlights the importance of prompt intervention based on clinical presentation to improve the prognosis of patients with this rare but serious condition [13].

4 Conclusions

This case underscores the importance of considering internal hernias in the differential diagnosis of acute intestinal obstruction, even in adults without previous surgical history. Diagnosing internal hernias is challenging due to the nonspecific symptoms and limited specificity of radiological imaging.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

The present study is the presentation of a clinical case, we point out that in our institution it is not necessary to be submitted to or approved by an ethics committee, the host institution to which we belong corresponds to the Hospital del Instituto de Seguridad y Servicios Sociales para lo Trabajadores del Estado, de Zapopan in the State of Jalisco.

Funding

Nothing to declare.

Guarantor

Quitzia Libertad Torres Salazar.

CRediT authorship contribution statement

AJGL - Diagnosis and follow-up and surgical approach plan

JAAG - Surgical assistant

NCB - File tracking and documentation

MAJM - Bibliographic review

TSQL - Article redaction.

Declaration of competing interest

Nothing to declare.
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