Internal Transmesenteric Hernia Causing Small Bowel Obstruction: A Case Report

Internal hernias often present with vague and nonspecific symptoms of bowel obstruction. However, they carry a potential for bowel ischemia; as such, they need immediate surgery. It is important to identify the etiology of small bowel obstruction as it may cause ischemia or strangulation of the bowel. Most guidelines suggest a wait-and-watch policy for small bowel obstruction. At the same time, if there are any signs of peritonitis, strangulation, or bowel ischemia, surgical exploration is recommended. We present a case of an 81-year-old man who came to the emergency department with complaints of vague but persistent abdominal pain. The pain was localized to the right flank and had become dull in nature. An abdominal X-ray showed a few air-fluid levels suggestive of subacute obstruction. The portable ultrasound was inconclusive. A non-contrast computed tomography (NCCT) scan of the abdomen was done for the non-resolution of pain. It revealed rotation/volvulus in the small bowel mesentery. A deeper look suggested the possibility of internal transmesenteric herniation with evidence of early bowel ischemia. Surgical exploration revealed ileal loops internally herniating inside a band of mesenteric tissue. The mesenteric band was cut, and the obstruction was relieved. Subsequently, the patient was discharged home.