Laparoscopic repair of a combined transmesocolic, transomental hernia.

Transmesocolic and transomental hernias (TOHs) are rare types of internal hernia. Both these hernias occurring concurrently in a patient are even rarer. We report a patient with signs of recurrent small-bowel obstruction who was found to have a dual transmesocolic, TOH. Computed tomography imaging and subsequent laparoscopic exploration identified small-bowel loops passing through a defect in the transverse mesocolon behind the stomach to emerge through the gastrohepatic omentum. This was treated successfully by laparoscopy. To the best of our knowledge, this is the first reported case of a combined transmesocolic, TOH undergoing successful laparoscopic repair.

INTRODUCTION

Internal hernias form a very small fraction (0.2%–0.9%) of cases presenting with intestinal obstruction.[1] In these patients, the diagnosis based on imaging modalities may often be delayed, resulting in up to 45% mortality.[2] A review of the literature revealed less than 15 reported cases of double omental hernia occurring through gastrocolic and gastrohepatic omentum, one of which was successfully treated by laparoscopy.[3] We report a rare case of a combined transmesocolic plus transomental internal hernia who underwent a successful laparoscopic repair.

CASE REPORT

A 54-year-old female presented with a history suggestive of recurrent episodes of small-bowel obstruction over 2 months. She had undergone a Wertheim's hysterectomy followed by radiotherapy for carcinoma cervix 2 years prior. This was followed by the development of a lymphocele that had required repeated tapping and a second course of radiotherapy for a small vaginal vault recurrence.

Initial diagnosis on admission was adhesive intestinal obstruction, and she was treated conservatively. An erect abdominal X-ray showed a large gastric bubble with few air–fluid levels present medially to it. All laboratory values were within normal limits. Following initial conservative management, a computed tomography (CT) enteroclysis was performed that showed gross dilatation of the stomach [Figure 1] and the distal stomach and the transverse colon placed posteroinferior to the mesentery and most of the small bowel. Some small-bowel loops were seen between the lesser curvature of the stomach and the left lobe of the liver [Figure 2]. These imaging findings were suspicious of an internal herniation, but the precise type of herniation could be not be identified on the CT scan.

Figure 1

Coronal view of abdominal computed tomography scan showing grossly dilated stomach

Figure 2

Abnormally placed small-bowel loops in the gastrohepatic omentum (arrow)

She was offered laparoscopic surgery. The first port was inserted by open laparoscopy well below the level of the umbilicus, and three additional 5-mm ports were placed. An abnormally dilated stomach was seen reaching up to the level of the umbilicus. Further exploration revealed a defect in the transverse mesocolon [Figure 3a] with significantly thinned out greater omentum. Roughly 20 cm of the proximal small bowel was seen protruding through the defect behind the stomach and re-emerging through a rent in the gastrohepatic omentum. This had distorted the anatomy and placed the duodenojejunal flexure directly behind the dilated stomach. The small-bowel loops were reduced from the mesocolic defect to correct the anatomy and bring the duodenojejunal flexure below the transverse colon. The mesocolic defect was closed by taking interrupted sutures of 2–0 polyester suture (Ethibond, Johnson and Johnson, India) between the edge of the defect and the first loop of the jejunum [Figure 3b]. The left transverse mesocolon was sutured to the posterior peritoneum, and a posterior gastropexy was performed by suturing of the greater curvature to the posterior peritoneum to obliterate the lesser sac [Figure 3c]. All the ports were closed in a standard fashion under vision. Post-operatively, the patient tolerated liquids on the 1st post-operative day and transitioned to regular diet at the time of discharge on the 3rd post-operative day. She has remained well some 26-month post-surgery.

Figure 3

(a) Defect in the transverse mesocolon (double-sided arrow). (b) Closure of the defect by approximation of its edges to the anterior wall of the first loop of the jejunum. (c) Suturing of posterior gastric wall to the posterior peritoneum

DISCUSSION

The reported frequencies of transmesocolic and transomental hernias (TOHs) are about 8% and 4%, respectively.[4] Only 15 instances of the two hernias occurring concurrently have been reported in the world literature.[5] These hernias can be difficult to diagnose pre-operatively even on a CT scan, as the classical 'stretched out' sign of the mesentery may not always be present.[16] Of all the three cases reported, one was diagnosed pre-operatively and the rest only at the time of laparotomy.[24] Delay in diagnosis and management may lead to high mortality owing to bowel ischaemia.[7]

Transmesenteric hernias can be iatrogenic, post-operative, traumatic, or inflammatory in origin. Three types of transmesenteric internal hernias have been described as follows: (a) transmesocolic, which are the most common; (b) herniation through small-bowel mesenteric defect and (c) Peterson hernia, in which small bowel herniates behind the Roux loop and passes through the transverse mesocolic defect.[5] In cases with transverse mesocolic hernias, small-bowel loops herniate into the lesser sac. When the mesocolic defect is large, there may be free egress of bowel loops between the lesser sac and peritoneal cavity without complications such as obstruction or strangulation developing.[8] On occasion, the bowel loops may re-enter the peritoneal cavity via the foramen of Winslow, the gastrohepatic ligament or the gastrocolic ligament.[6] In our case, the small-bowel loops had herniated in the lesser sac via a mesocolic defect and emerged via the gastrohepatic omentum.

Depending on the type of transmesenteric hernia and the segment and length of the herniated bowel, imaging appearances may vary.[1] In our case, the appearance of CT was questionable for this type of abdominal pathology. Defect in the transverse mesocolon had provided access for internal herniation of small-bowel loops posterior to the transverse colon into the lesser sac. Re-entry into the greater peritoneal cavity was via the gastrohepatic ligament.

A TOH has no hernial sac and often occurs in individuals over the age of 50 years. The hernia defect may be congenital or acquired, the latter forming secondary to trauma, an inflammatory pathology or due to an age-related weakness in the greater or lesser omentum.[3] In rare instances, the TOH may occur spontaneously.[4] Although our patient had a previous surgery in the form of a Wertheim's hysterectomy, the defects in the transverse mesocolon and gastrohepatic omentum could not be explained on the basis of that surgery. In the Takeyama et al. classification of TOH, herniation through the free greater omentum and into the lesser sac through the defect in the gastrocolic ligament has been mentioned.[1] However, in our case, the herniation was into the lesser sac and then into the peritoneal cavity across the lesser omentum as proposed by Kundaragi et al.[5] A case of double OH managed by Talebpour et al. remains as the only reported case of a double internal hernia managed in a minimally invasive manner.[2] In their patient, small bowel had herniated through the gastrocolic omentum into the lesser sac and re-emerged through the gastrohepatic omentum. This was reduced at laparoscopy, and both the defects were repaired. To the best of our knowledge, ours is the first case of a double transmesocolic, TOH managed successfully by laparoscopy. All three prior reported cases have been presented with details that are compared with our case in Table 1. None of the cases had any upper abdominal surgery performed and hence do not appear to have any reason to suspect iatrogenic adhesions as the cause of internal herniation. Only the first reported case of such a herniation required bowel resection for gangrene.[6]

Table 1

Comparison of cases of transmesocolic/transomental hernia

Author	Chattopadhyay et al.[6]	Chou et al.[4]	Kundaragi et al.[5]	Kulkarni et al.
Country/year	India/1982	China/2004	India/2014	India/2018
Age/gender	28/female	17/female	55/male	54/female
Duration of symptoms	9 years	1 year	1 day	2 months
Prior abdominal surgery	No	No	No	Hysterectomy
Delay in surgery	9 days	2 days	1 day	1 day
Type of surgery	Open	Open	Open	Laparoscopic
Bowel resection	Yes	No	No	No

In conclusion, transomental, transmesocolic double hernia is a rare form of internal hernia. In patients with episodes of acute abdominal pain and obstruction with or without a history of prior surgical intervention, an internal herniation should be considered. A contrast CT scan is a gold standard for diagnosis, and as in our case a rapid diagnosis can reduce the complications and increase the likelihood of the procedure being completed by a minimally invasive approach. The laparoscopic approach is suggested whenever the expertise is available in view of the reduced post-operative morbidity, shorter hospital stay and enhanced recovery.

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Conflicts of interest

There are no conflicts of interest.