Congenital transmesenteric internal hernia; A rare cause of bowel ischemia in adults: A case report

J Surg Med. 2019;3(7):539-541. DOI: 10.28982/josam.543160 Case report Olgu sunumu Congenital transmesenteric internal hernia; A rare cause of bowel ischemia in adults: A case report Konjenital transmesenterik internal herni; Erişkinlerde nadir bir barsak iskemi nedeni: Olgu sunumu Hamza Hasnaoui 1,2, Ouadii Mouaqit 1,2, Mohamed Lemine Beillahi 1,2, Hicham El Bouhaddouti 1,2, El Bachir Benjelloun 1,2, Abdelmalek Ousadden 1,2, Khalid Ait Taleb 1,2 1 Visceral Surgery Department A, CHU Hassan II, Fez, Morocco 2 Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University of Fez, Morocco ORCID ID of the author(s) HH: 0000-0002-6693-2842 MO: 0000-0003-3286-7568 MLB: 0000-0001-6526-9295 HEB: 0000-0001-8881-0101 EBB: 0000-0002-3176-6899 OA: 0000-0001-5225-8546 ATK: 0000-0002-0920-796X Corresponding author / Sorumlu yazar: Hamza Hasnaoui Address / Adres: Visceral Surgery Department A, CHU Hassan II, Fez, Morocco. Faculty of Medicine and Pharmacy - Sidi Mohamed Ben Abdellah University of Fez, Morocco e-Mail: ⸺ Informed Consent: The authors stated that the written consent was obtained from the patient presented with images in the study. Hasta Onamı: Yazar çalışmada görüntüleri sunulan hastadan yazılı onam alındığını ifade etmiştir. ⸺ Conflict of Interest: No conflict of interest was declared by the authors. Çıkar Çatışması: Yazarlar çıkar çatışması bildirmemişlerdir. ⸺ Financial Disclosure: The authors declared that this study has received no financial support. Finansal Destek: Yazarlar bu çalışma için finansal destek almadıklarını beyan etmişlerdir. ⸺ Published: 7/24/2019 Yayın Tarihi: 24.07.2019 Abstract Congenital transmesenteric hernias represent a very small group of internal hernias which are uncommon and are a rare cause of bowel obstruction and bowel ischemia in adults with few reported cases in published literature. Preoperative diagnosis of the condition is difficult, early intervention and surgical correction goes a long way in preventing high morbidity and mortality associated with cases of internal hernia. We present a case of true congenital transmesenteric hernia in a 31-year-old woman with no previous surgical history or trauma who presented with history of severe abdominal pain and the cessation of both feces and flatus. The abdominal CT scan could not confirm the diagnosis. The patient was operated upon on account of increasing abdominal pain and distention associated with shock. An exploratory laparotomy revealed a congenital transmesenteric defect through which loops of bowel had herniated and become gangrenous, resulting in resection and a stomy type Bouilly Volkmann. Keywords: Congenital transmesenteric defect, Internal hernia, Bowel ischemia Öz Konjenital transmesenterik fıtıklar, nadir görülen ve yayınlanmış literatürde az sayıda bildirilmiş vaka ile erişkinlerde nadir görülen bir barsak tıkanıklığı ve barsak iskemi nedeni olan çok küçük bir iç fıtık grubunu temsil eder. Hastalığın preoperatif tanısı zordur, erken müdahale ve cerrahi düzeltme, içsel fıtık vakalarına bağlı yüksek morbidite ve mortaliteyi önlemede uzun bir yol kat eder. Daha önce cerrahi öyküsü veya travması olmayan 31 yaşında bir kadın hastada gerçek konjenital transmesenterik herni olgusunu sunuyoruz. Şiddetli karın ağrısı öyküsü ve hem dışkı hem de flatusun kesilmesi ile başvurdu. Abdominal BT taraması tanıyı doğrulayamadı. Hasta abdominal ağrının artması ve şokla ilişkili distansiyon nedeniyle ameliyat edildi. Bir keşif laparotomisi, barsak ilmeklerinin fıtıklandığı ve kangrenli hale gelen doğuştan bir transmesenterik defekti ortaya çıkardı, rezeksiyona ve bir stomi türü Bouilly Volkmann'a neden oldu. Anahtar kelimeler: Konjenital transmesenterik defekt, İnternal fıtık, Bağırsak iskemi Introduction Internal hernia is a rare cause of intestinal obstruction in adults. Of internal hernia congenital transmesenteric hernia only constitute an estimated 5–10% of cases [1]. Congenital transmesenteric internal hernia is a very rare but definite acute surgical condition requiring early diagnosis. In almost all cases presentation is acute intestinal obstruction or recurrent pain abdomen due to mesenteric ischemia without definite clinical symptoms or signs. In published literature only 36 patients have suffered from bowel obstruction and 9 from ensuing ischemia secondary to transmesenteric hernia [2,3]. Almost all reported cases are diagnosed intraoperatively. Copyright © 2019 The Author(s) Published by JOSAM This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-NoDerivatives License 4.0 (CC BY-NC-ND 4.0) where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. How to cite / Atıf için: Hasnaoui H, Mouaqit O, Beillahi ML, EL Bouhaddouti H, Benjelloun EB, Ousadden A, AIT Taleb K. Congenital transmesenteric internal hernia; A rare cause of bowel ischemia in adults: A case report. J Surg Med. 2019;3(7):539-541. P a g e / S a y f a | 539 J Surg Med. 2019;3(7):539-541. Congenital transmesenteric internal hernia Case presentation A 31-year-old woman was admitted to general surgery emergency with a five-day history of constipation, progressive abdominal pain, nausea and vomiting. The last bowel movement had been two days ago. There was no significant past medical history especially of chronic constipation, psychiatric disease, trauma or abdominal surgery. There was no other relevant past personal or family history. On examination, the vital signs were: Temperature 39˚C, Pulse 115/min, Respiratory rate 26/min, Blood pressure 90/60 mmHg. Abdominal examination revealed a distension of the abdomen without signs of peritonitis. The abdomen was tympanic to percussion. There were no umbilical or groin hernias. Digital rectal examination demonstrated an empty rectal vault without intraluminal masses. Further systemic examination was unremarkable. The abdominal X-ray revealed few gas distended bowel loops (Figure 1). Blood investigations showed leukocytosis at 26.000 e/dl, CRP at 148 mg/l, serum sodium and potassium levels were within normal limits. Functional renal failure: serum urea 0.6 g/l, blood creatinine at 12mg/l. The abdominal computed tomography: showed crowded and stretched mesenteric vessels, dilated and clustered small bowel, thickened intestinal wall (Figure 2). 4 hours after admission, the patient worsened her abdominal pain and her hemodynamic became unstable. After initial resuscitation with intravenous fluids, analgesics and antibiotics, decision was taken to proceed for an emergency laparotomy. Intra operative findings approximately 1 m 50 cm of gangrenous small bowel, proximal ileum herniating (Figure 3) through a congenital small bowel mesenteric defect (Figure 4). The hernia was reduced, the mesenteric defect was repaired, small bowel resected and stomy type Bouilly Volkmann performed (...truncated)