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Congenital trans-mesenteric herniation: a rare cause of small intestine strangulation in adults.


An internal hernia is defined as the protrusion of a viscus through a normal or an abnormal opening within the boundaries of the peritoneal cavity.

Trans-mesenteric hernia is a type of internal hernia which is an unusual cause of bowel obstruction. It may result in irreversible damage of the bowel and a fatal outcome. Less than 1% of the cause of small bowel obstruction is due to internal hernia [1, 2].

Paraduodenal hernia continues to be the most common type of internal hernia (50%) in the abdomen without prior surgery [3, 4] compared with trans-mesenteric hernia in which the incidence ranged from 8 to 10% [5, 6].

Most of the reports of congenital trans-mesenteric hernia involve the pediatric population but even in this group of patients, the trans-mesenteric defect is infrequent [7, 8].


A 21-year-old woman who was otherwise healthy before presented with severe abdominal pain. The pain was generalized, severe, acute onset and continuous. She was also found to have multiple episodes of vomiting for a period of 24 h. Otherwise, she had no fever, no history of previous abdominal surgery, no other co-morbids and no trauma.

On examination she was drowsy, tachycardic with a pulse rate of 120 beats/min, BP 130/78 mmHg, temperature 37.0[degrees]C, dehydrated and respiratory rate of 24 breaths/min. An abdominal examination revealed distended abdomen, generalized abdominal tenderness and guarding. Bowel sounds were absent.

Laboratory investigations results were normal, except for an elevated white blood cell count of 16 000/[mm.sup.3].

In view of generalized peritonitis, the abdomen was explored through an emergency midline laparotomy after initial resuscitation.

Upon entering the peritoneal cavity, 2 l of hemorrhagic fluid was drained. A loop of ileum had herniated through a small mesenteric defect. A total of 180 cm ileum noted to be gangrenous with loss of peristalsis and absent pulsations (Fig. 1). Terminal ileum and the ileocecal junction were also nonviable. Pulsations of mesenteric vessels were intact. The mesenteric defect measuring 3 x 3 cm located about 4 cm from the mesenteric edge of mid-jejunum. There was no evidence of malrotation. A limited right hemicolectomy with extensive gangrenous small bowel resection was performed and a stapled side-to-side functional anastomosis created. The mesenteric defect mentioned earlier was closed with interrupted sutures. The patient recovered well from the surgery. She was allowed orally on day 3 post surgery (Figs 2-4).




Congenital defects in the mesentery have been described as an uncommon pathology, presented mainly in the pediatric population [9] and these are very rare in adults.

However, in this case we are reporting the mesenteric defect to be congenital and the cause for the bowel strangulation. Defects are most commonly acquired in adults as a result of either blunt abdominal trauma or surgical manipulation of the bowel and mesentery.



Most of the literature reports that the most common form of presentation is an acute intestinal obstruction which is also the clinical presentation of our patient. It could be an intermittent obstruction as well, which delays the diagnosis and treatment [8, 10].

As it is an uncommon etiology for intestinal obstruction most of the congenital mesenteric hernia diagnoses are made during the operative time.

Most of the time clinical features such as peritonitis and acute intestinal obstruction warrant for an immediate surgical intervention.

Morbidity and mortality of the condition depend mainly on the time of onset, clinical severity, the patient's co-morbidities and vascular compromise.


Conflict of interest statement

None declared.

Received 28 July 2012; accepted 1 September 2012


[1.] Ghahremani GG. Abdominal and pelvic hernias. In: Gore RM, Levine MS. Textbook of Gastrointestinal Radiology, 2nd edn. Philadelphia, PA: Saunders, 2000, 1993-2009.

[2.] Newsom BD, Kukora JS. Congenital and acquired internal hernias: unusual causes of small bowel obstruction. Am J Surg 1986;152:279-84.

[3.] 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.

[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.

[5.] Newsome BD, Kukora JS. Congenital and acquired internal hernias: unusual causes of small bowel obstruction. Am J Surg 1986;152:27985.

[6.] Ghahremani G. Internal abdominal hernias. Surg Clin North Am 1984;64:393-406.

[7.] Alvear DT, Jacobs RA. Case report: congenital mesocolic hernia. Pa Med 1976;79:76-8.

[8.] Merrot T. Small bowel obstruction caused by congenital mesocolic hernia: a case report. J Pediatr Surg 2003;38:38.

[9.] Murphy DA. Internal hernias in infancy and childhood. Surgery 1964;55:311-6.

[10.] Ghiassi S. Internal hernias: clinical findings, management, and outcomes in 49 non-bariatric cases. J Gastrointest Surg 2007;11:291-5.

Umaparan G *, Kumareson Nallusamy, Md Hamsan Abdul Wahab, Ahmad Muhsin Mohammad Nor and Nor Aishah Mat Arif

Surgery, Ampang General Hospital, Pandan Mewah, Jalan Mewah Utara, Ampang, Selangor, Malaysia

* Correspondence address. Department of Surgery, Ampang General Hospital, Pandan Mewah, Jalan Mewah Utara, Ampang, Selangor, Malaysia. Tel: +60-126855084; Fax: +60-342954666; E-mail:
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Title Annotation:Case Report
Author:Umaparan G.; Nallusamy, Kumareson; Wahab, Md Hamsan Abdul; Mohammad Nor, Ahmad Muhsin; Arif, Nor Ais
Publication:Journal of Surgical Case Reports
Article Type:Case study
Date:Nov 1, 2012
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