Spontaneous Transmesenteric Hernia: A Rare Cause of Small Bowel Obstruction in an Adult
A 28-year-old female presented to emergency department with complaints of generalized abdominal pain, non-passage of feces and flatus, and multiple episodes of vomiting of 4 days duration. There was no history of surgery and no comorbidities. On examination, there was tachycardia, hypotension, and signs of dehydration. Abdomen examination revealed generalized distension, diffuse tenderness, guarding and absent bowel sounds. Hematological and biochemical investigations revealed leukocytosis with neutrophilia, raised blood urea and serum creatinine. X-ray chest and abdomen showed no free gas under diaphragm, there were multiple air fluid levels, and dilated small bowel loops. Ultrasonography of abdomen showed dilated small bowel loops with moderate amount of interbowel fluid. As there were signs of septic shock, and strangulation, and renal function tests were deranged, contrast enhanced computed tomography (CECT) was not performed. With the diagnosis of small bowel obstruction and a possibility of strangulation, after nasogastric decompression, aggressive preoperative fluid replacement, and correction of electrolyte disturbances, emergency exploratory laparotomy was done. On exploration, small bowel loops were dilated, and a long segment of small bowel were infarcted. The mid, distal jejunum and proximal ileal loops were found to pass through a defect in the proximal jejunal mesentery () with compression of vascularization of herniated bowel loops (). Rest of the small bowel, colon and stomach were normal. After reduction of herniated bowel loops, resection of the gangrenous loops with end to end anastomosis between proximal jejunum and mid ileum was performed and mesenteric defect was closed properly. Postoperative period was uneventful and patient was discharged on postoperative day 8.