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A Rare Case of Intestinal Obstruction Transomental Hernia
Faisal El Mouhafid*, Sore Abdoulmalik, Mohamed ES-Said Ramraoui, Jawad Fassi Fihri, Hicham Baba, Mohammed Lahkim, El Khader Ahmed and Elbarni Rachid
Department of general surgery, avicenne military teaching hospital, Marrakech, Morocco
Received Date: 04/11/2024; Published Date: 23/12/2024
*Corresponding author: Faisal El Mouhafid, Department of general surgery, avicenne military teaching hospital, Marrakech, Morocco
Abstract
We report the case of a 70-year-old patient with a transomental hernia complicated by intestinal obstruction who underwent median laparotomy.
Keywords: Internal hernia; Transomental hernia; Intestinal obstruction; Small intestine
Introduction
Internal hernias are defined as a protrusion of hollow viscera through an intraperitoneal orifice and which remains in the abdominal cavity [1,2]. They constitute a rare cause of intestinal obstruction. In fact, they can be responsible for 0.2 to 5.8% of small intestinal obstructions [3]. Depending on their physiopathological mechanism, we distinguish several types, among which the transomental hernia constitutes one of the most exceptional and represents only 2% of internal hernias [1].
The trans-omental hernia is said to be true if the incarceration of the loops takes place in an orifice located near the free edge of the greater omentum on the right side [1].
The etiological diagnosis of a transomental hernia is not easy. The diagnosis is most often made intraoperatively in a patient with intestinal obstruction.
Clinical Case
It was a 70-year-old man who was seen in the emergency room for abdominal pain with vomiting and cessation of materials and gas.
During questioning, the patient reported that the symptoms began approximately 24 hours ago, with a twisting pain located in the periumbilical area radiating to the flank with food and then bilious vomiting, all evolving in an afebrile context. He would be type 2 diabetic under treatment.
The patient's clinical examination revealed:
On general examination: general condition WHO stage 2, Glasgow at 15, vital constants T: 37.9; CF: 94; BP: 110/64.
On physical examination: a distended abdomen, tympanic, diffusely painful on palpation of the free parietal hernial orifices and rectal examination with an empty rectal ampulla.
The paraclinical examination:
On the biological assessment, an elevation of the CRP to160, hyperleuocytosis with a neutrophil predominance, no ionic disorders.
At the ASP we had hail-like hydro-aerial levels, we completed with Abdominal CT which showed hydro-aerial levels with small bowel distension with disparity in caliber without sign of damage to the loops.
The patient underwent a median laparotomy above and below the umbilical with the intra-op observation of an omental hernia by incarceration of ileal loops without signs of necrosis
through a defect in the greater omentum of approximately 4 cm without other anomalies to exploration (Figure1). We therefore carried out extrication of the ileal loops with closure of the defect using separate points with 3/0 vycril (Figure 2).
The postoperative course was simple and the patient was allowed to leave the hospital on the 7th post-operative day.
Figure 1: The surgical pictures of Transomental internal hernias.
Figure 2: Viable small intestine.
Discussion
Internal hernias constitute an unusual pathology in current practice; among its different varieties, transomental hernias are one of the rarest and represent only 2% of cases of internal hernias [1].
Transomental internal hernias are observed in patients who have no previous abdominal surgery, as is the case in our patient. They occur most often in patients aged over 50 [4] as in our case. These hernias can be seen in both sexes but are more common in males.
In our case, the hernia was revealed by an occlusive syndrome which is the most common mode of manifestation of this type of hernia when the incarcerated small bowel loops are strangulated [5]. The previously difficult preoperative etiological diagnosis is made easier by the more frequent use of CT. MRI is a better diagnostic tool than CT but is most often not available in an emergency. In our case, the etiological diagnosis of the occlusion was made intraoperatively.
The standard treatment for this type of pathology consists of a laparotomy to remove the obstacle and closure of the defect to avoid the occurrence of intestinal necrosis or recurrence, hence the need for early treatment.
Conclusion
Transomental hernias constitute a rare pathology in current practice whose etiological diagnosis is facilitated by imaging techniques. They can constitute a medico-surgical emergency in the event of a diagnostic and therapeutic delay.
References
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