Strangulated Internal Hernia through the Lesser Sac – An Unusual Cause of Small Bowel Obstruction

Special Article - Surgical Case Reports

Austin J Surg. 2015; 2(6): 1072.

Strangulated Internal Hernia through the Lesser Sac – An Unusual Cause of Small Bowel Obstruction

Sangram Keshari Panda¹* and Amita Panda²

¹Department of General Surgery, Kalinga Institute of Medical Science, India

²M.K.C.G Medical College, India

*Corresponding author: Sangram Keshari Panda, Senior Resident, Department of General Surgery, Bhubaneswar, Odisha, India

Received: August 17, 2015; Accepted: September 21, 2015; Published: September 25, 2015

Abstract

Introduction: The incidence of internal hernias is 0.2% to 2%. It is a rare cause of intestinal obstruction and leads from 0.5 to 4.1% of acute obstruction cases caused by hernia.

Presentation of Case: We report a case of internal hernia traversing the lesser sac with a primary defect in the greater omentum and a second defect in the lesser omentum, causing small bowel obstruction which is extremely rare.

Discussion: The most common causes of small bowel obstruction in adults are adhesions bands, malignancy and hernias. Internal Hernia (IH) is defined as herniation of viscera through a normal or abnormal aperture within the peritoneal cavity. Internal hernias are infrequent, accounting for 0.2 to 0.9% of the cases of intestinal obstruction. Transomental hernias through the greater or lesser omentum are even rarer, representing 1 to 4% of all internal hernias, with hernias occurring through both the omentum being extremely rare as in our case.

Conclusion: When a case of acute intestinal obstruction is reported, after ruling out the known causes of obstruction, surgeon should have high suspicion of internal hernia to reduce the risk of intestinal ischemia, necrosis and perforation; thus decreasing the postoperative morbidity and mortality.

Keywords: Strangulated internal hernia; Intestinal obstruction; Absolute constipation; Lesser sac

Introduction

An internal hernia is defined as the protrusion of a viscous through a normal or abnormal opening within the confines of the abdominal cavity [1]. The classification is based on anatomic regions where internal hernias with distinctive clinical and radiographic features occur: paraduodenal (left > right) (53%), foramen of Winslow (8%), pericecal (13%), Inter sigmoid (6%), Transmesenteric (8%), Transomental (1–4%), Retroanastomotic, Supravesical and pelvic (6%) [2]. The incidence of internal hernias is 0.2% to 2%. It is a rare cause of intestinal obstruction and leads from 0.5 to 4.1% of acute obstruction cases caused by hernia [3]. We report a case of internal hernia traversing the lesser sac with a primary defect in the greater omentum and a second defect in the lesser omentum, causing small bowel obstruction which is extremely rare.

Case Report

A 32 year old male patient was admitted to emergency department of SCB Medical College & hospital, Cuttack with complaints of repeated episodes of vomiting, absolute constipation, colicky abdominal pain and abdominal distension of duration two days. He had no past history of tuberculosis or any abdominal surgery. There is no similar incidence in the past. Upon clinical examination, patient was dehydrated and afebrile with a pulse rate of 96/min and a blood pressure of 102/ 58 mm of Hg. On abdominal examination, abdomen was distended, non tender, no visible peristalsis and bowel sounds were absent. On digital rectal examination, rectum was normal. Hematological and biochemical investigations were within normal limit. Plain X-ray abdomen showed multiple air fluid levels. Abdominal ultra sonography was performed which did not reveal any significant information. A nasogastric tube was inserted. With a diagnosis of acute intestinal obstruction, the patient underwent an exploratory laparotomy that revealed about 90-cm proximal ileal segment herniated through an opening in the greater omentum (Figure 1) and came out through the second opening in the lesser omentum after traversing the lesser sac. The ileal segment was strangulated in the secondary defect in the lesser omentum (Figure 2). Upon widening the hernial orifice and resecting both ends of the strangulated bowel, the ischemic bowel was removed and a primary anastomosis was performed. The hernial defects were repaired. The postoperative course was uneventful and the patient was discharged on 10th postoperative day. He was followed up as an outpatient for 3 months and had no further difficulties.

Citation: Panda SK and Panda A. Strangulated Internal Hernia through the Lesser Sac – An Unusual Cause of Small Bowel Obstruction. Austin J Surg. 2015; 2(6): 1072. ISSN : 2381-9030