AJR 2005; 184:1532-1534
© American Roentgen Ray Society
Combined Transmesocolic–Transomental Internal Hernia
Chung Kuao Chou1,
Chee-Wai Mak,
Reng-Hong Wu and
Jinn-Ming Chang
1 All authors: Department of Radiology, Chi Mei Medical Center, 901 Chung Hwa
Rd., Tainan 71010, Taiwan, Republic of China.
Received March 15, 2004;
accepted after revision August 17, 2004.
Address correspondence to C. K. Chou
(cmh5200{at}mail.chimei.org.tw).
Introduction
Internal hernia of the small bowel into the lesser sac through a defect in
the transverse mesocolon has been described
[1–4].
The herniated small bowel may be seen above the gastric lower body and to the
right of the gastric upper body on the anteroposterior projection and dorsal
to the stomach and the transverse colon on the lateral projection of
radiographs and barium studies. It may reenter into the greater peritoneal
cavity via the foramen of Winslow or a defect in either the gastrohepatic or
the gastrocolic ligament
[5].
The imaging findings of these combined hernias are scant
[4]. Because of the potential
risks of small-bowel obstruction, strangulation, and gangrene, timely
diagnosis is important. We report the CT findings, which have not been
described to our knowledge, of a case of spontaneous herniation of the small
bowel through a defect in the transverse mesocolon and the lesser omentum (the
gastrohepatic ligament) into the right upper greater peritoneal cavity.
Case Report
A 17-year-old girl who had abdominal pain of 2 days' duration was sent to
the emergency department. It was vague epigastric pain in the beginning and
migrated to the right lower quadrant later. Physical examination revealed
lower abdominal rebounding pain. The laboratory data were noncontributory
except an increased WBC value (16,100/µL) and a neutrophilic predominance
(82%). The patient experienced a similar attack with spontaneous remission
about 1 year earlier. However, no specific diagnosis was made for that attack.
She denied any abdominal injury, surgery, or intraabdominal inflammatory
process.
An emergent CT examination revealed that a long small-bowel segment was
abnormally located in the right upper quadrant and its vessels were convergent
at a level cephalad to the gastric body and transverse colon (Fig.
1A,
1B,
1C). After a detailed analysis
on the anatomic relationships among the stomach, the transverse colon, and the
small bowel and its associated vessels, we made a preoperative diagnosis of
combined transmesocolic and transomental hernia. An emergent laparotomy was
performed 6 hr after the CT examination. The surgeons found a cyanotic
small-bowel segment, approximately 150 cm long and 80 cm distal to the
ligament of Treitz, herniating through a defect in the transverse mesocolon
and a defect in the lesser omentum to the right upper quadrant. They
successfully pushed the small bowel back to the inframesocolic peritoneal
cavity and repaired these two defects. The patient recovered uneventfully.
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Fig. 1A. —17-year-old girl with combined transmesocolic and
transomental internal hernia. Contrast-enhanced CT scan reveals convergence of
herniated mesenteric vessels and normal main trunks of superior mesenteric
vessels. This converging point represented defect in gastrohepatic ligament
(lesser omentum). Gastric upper body and antrum were on left and right sides
of converging vessels, respectively. CHV = convergence of herniated mesenteric
vessels, SMv = superior mesenteric vessels, GUB = gastric upper body, GA =
gastric antrum, PTC = proximal transverse colon, DTC = distal transverse
colon.
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Fig. 1B. —17-year-old girl with combined transmesocolic and
transomental internal hernia. Contrast-enhanced CT scan obtained at level 3 cm
caudad to A shows herniated mesenteric vessels coursing, ventral to
stretched gastric lower body, to lower peritoneal cavity. HV = herniated
mesenteric vessels, GLB = gastric lower body.
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Fig. 1C. —17-year-old girl with combined transmesocolic and
transomental internal hernia. Contrast-enhanced CT scan obtained at level 2 cm
caudad to B shows herniated small bowel was ventral to transverse colon
(TC).
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Discussion
Internal hernias through a defect in the lesser omentum, greater omentum,
mesentery, transverse mesocolon, and sigmoid mesocolon are rare
[1–11].
These defects may be congenital, traumatic, postoperative, postinflammatory,
or idiopathic. The herniated bowel may return to its normal location or be
incarcerated depending on the size of the defect and the length of the
herniated bowel. Internal hernias are diagnosed by the football sign on
radiography; abnormal location of the small bowel, fixed and circumscribed
small-bowel loops, and the closely approximated, constricted afferent and
efferent limbs are diagnostic on barium study and CT
[4]. Besides these images, CT
can further delineate the anatomic relationships among the small bowel and its
associated vessels and the adjacent organs.
Carlisle and Killen [5]
reviewed 19 cases of transmesocolic hernia of the small bowel into the lesser
sac through a defect in the transverse mesocolon with further reentry into the
greater peritoneal cavity via the foramen of Winslow (two cases) or a defect
in either the gastrohepatic ligament (12 cases) or the gastrocolic ligament
(five cases). The most common symptoms in those cases were chronic gastric
outlet obstruction and chronic abdominal pain
[5]. However, the imaging
findings of these combined hernias were scant
[4].
The first unique CT finding in our patient was an unusual course of the
herniated small-bowel vessels. They arose from the main trunks of the superior
mesenteric vessels and converged at a level cephalad to the gastric lower body
with the gastric upper body and antrum on the left and right sides of this
converging zone (Fig. 1A),
respectively. Then they went, ventral to the gastric lower body, to the lower
peritoneal cavity (Fig. 1B). In
general condition, the jejunal vessels are recognized at a level dorsal and
caudad to the gastric body. The second unique CT finding in our patient was an
unusual location of the small bowel. The proximal small bowel in this case was
in the right upper quadrant at a level cephalad to the hepatic flexure of the
colon and ventral to the transverse colon
(Fig. 1C).
When in normal condition, the small bowel is in the inframesocolic
compartment, caudad to the colonic hepatic flexure and dorsal to the
transverse colon. The abnormal vascular course and small-bowel location seen
in our patient helped us correctly imagine a herniation of the small bowel
through a defect in the transverse mesocolon and a defect in the lesser
omentum into the right upper peritoneal cavity (Fig.
2A,
2B).
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Fig. 2A. —Diagrams show three levels (dotted lines)
corresponding to levels shown in Figures 1A (A), 1B (B), and 1C (C). and
B, Diagrams of coronal (A) and sagittal (B) views depict
different levels at which CT scans in Figure
1A,
1B,
1C were obtained. LO = lesser
omentum, TMC = transverse mesocolon, S = stomach, TC = transverse colon. PTC =
proximal transverse colon, DTC = distal transverse colon, PSB = proximal small
bowel, DSB = distal small bowel, GCL = gastrocolic ligament, GO = greater
omentum.
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Fig. 2B. —Diagrams show three levels (dotted lines)
corresponding to levels shown in Figures
1A (A),
1B (B), and
1C (C). Diagrams of coronal
(A) and sagittal (B) views depict different levels at which CT
scans in Figure 1A,
1B,
1C were obtained. LO = lesser
omentum, TMC = transverse mesocolon, S = stomach, TC = transverse colon. PTC =
proximal transverse colon, DTC = distal transverse colon, PSB = proximal small
bowel, DSB = distal small bowel, GCL = gastrocolic ligament, GO = greater
omentum.
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Our case indicated that visualization of an abnormal vascular course on CT,
a finding that is not available by radiography or barium study, is valuable in
the detection of a specific internal hernia.
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Introduction
Case Report
