Tendeng JN., et al. Surg Chron 2021; 26(3); 319-322.

Internal Hernia Causing Bowel Obstruction: About 3 Cases And Literature

Review
Jacques Noël TENDENG 1, , Abdourahmane NDONG 1, , Adja Coumba DIALLO 1, , Moustapha DIEDHIOU 2, , Saër DIOP1,
Mohamed Lamine DIAO 1, , Philippe MANYACKA 1, , Ibrahima KONATE 1
1 Department of General Surgery, Gaston Berger University, Sénégal
2 Department of anaesthesia and intensive care, Gaston Berger University, Sénégal

Summary
Background: Strangulated internal hernias are rare. They are defined by a protrusion of small bowel or other abdominal organs
through a normal or abnormal orifice in the peritoneum or mesentery into the abdominal cavity that may lead to strangulation.
Internal hernias may be congenital or acquired postoperatively (bypass surgery or liver transplantation). They are often
asymptomatic and are often discovered during acute intestinal obstruction. CT scan has a key place for the preoperative diagnosis.
Otherwise, internal hernias are often discovered during surgical exploration.
Cases presentation: We report 3 cases of internal hernias revealed by acute intestinal obstruction to discuss diagnostic and
therapeutic aspects. These were internal hernias through an abnormal orifice including 2 trans-mesenteric with necrotic small
bowel and 1 trans-mesocolic without necrosis. A closure of the orifice were performed with and Bowel resection and anastomosis
in case of necrosis. The post-operative course was uneventful in all cases.
Conclusion: Strangulated internal hernia is infrequent. The preoperative diagnosis without CT scan is difficult. Exploratory
laparotomy can confirm the diagnosis and its topography. The treatment consists of the reduction of the contents followed by a
closure of the defect.

Key words: hernia, emergency, trans-mesenteric, trans-mesocolic

Introduction
Strangulated internal hernias are rare. They are defined by a
protrusion of small bowel or other abdominal organs
through a normal or abnormal orifice in the peritoneum or
mesentery into the abdominal cavity that may lead to
strangulation [1]. Internal hernias may be congenital or
acquired postoperatively (bypass surgery or liver
transplantation) [2,3]. They are often asymptomatic and are
often discovered during acute intestinal obstruction [4]. CT
scan has a key place for the preoperative diagnosis.
Otherwise, internal hernias are often discovered during
surgical exploration [1]. We report 3 cases of internal hernias
revealed by acute intestinal obstruction to discuss diagnostic
and therapeutic aspects.

Cases presentation
Case 1
It was a 26-years-old man, with no medical history who
consulted the emergency department for diffuse acute
abdominal pain predominantly epigastric. These symptoms
were associated with vomiting and absence of passage
of stool and flatus evolving over the past 24 hours.
The patient was apyretic and his general condition was
preserved. Examination showed a distended abdomen with
normal hernial orifices. A digital rectal examination revealed
an empty rectum. Plain abdominal radiography found hydro-
aeric levels (Figure 1).
Figure 1: Plain abdominal radiography showing hydro-aeric levels
(case 1)
CT scan was not available for emergency use. The biology
showed signs of hemoconcentration. The diagnosis of small
bowel obstruction was made and an exploratory laparotomy
was decided. It showed a strangulated internal hernia with
the passage of the jejunum through an orifice in the
transverse mesocolon (Figure 2). After reduction of the
hernia contents, there was no bowel necrosis and the orifice
was closed by interrupted sutures. The postoperative course
was uneventful and the patient was discharged 3 days after
the surgery.

319

Figure 2: Intra-operative image showing a trans-meso-colic
defect (case 1)
Case 2
A 28-years-old woman with no particular history consulted
to the emergency department for diffuse abdominal pain. It
was associated with vomiting evolving for 48 hours.
Examination showed a fever (38.2° C) with moderate
dehydration. Abdominal examination showed a diffuse
meteorism with generalized abdominal tenderness. The
hernial orifices were normal and the digital rectal exam
found no abnormalities. Plain abdominal radiography
showed small bowel obstruction with hydro-aeric levels
(Figure 3).
Figure 3: Plain abdominal radiography showing hydro-aeric levels
(case 2)
The biology showed hyponatremia at 130 mmol/L. After
correction of the hydro-electrolytic disorders, an exploratory
laparotomy was performed. It revealed a strangulated trans-
mesenteric internal hernia located at 80 cm from the
ileocecal valve containing 90 cm of necrotic small bowel
(Figure 4). Bowel resection and anastomosis followed by the
closure of the mesenteric orifice were performed. There was
Tendeng JN., et al. Surg Chron 2021; 26(3); 319-322.
no post-operative complications and the patient was
discharged 6 days after the surgery.
Figure 4: Intra-operative image showing a strangulated trans-
mesenteric hernia with necrotic small bowel (case 2)
Case 3
The patient was 60 years old with no particular medical
history. He consulted for abdominal pain evolving for 72
hours. Associated symptoms were vomiting and
absence of passage of stool and flatus. The patient had a
fever (38°C) with a good general condition. Examination of
the abdomen revealed a diffuse meteorism and tenderness.
The digital rectal exam was normal. Plain abdominal
radiography showed small bowel obstruction with hydro-
aeric levels (Figure 5).
Figure 5: Plain abdominal radiography showing hydro-aeric levels
(Case 3)
Biology showed anemia at 8.1g/dL with leukocytosis at
21500 elements/mm3. After blood transfusions, an
exploratory laparotomy was realized. It showed a
320

strangulated trans-mesenteric hernia located 130 cm from
the ileocecal valve containing 60 cm of necrotic small bowel
(Figure 6). Bowel resection with end-to-end anastomosis and
closure of the mesenteric defect was performed. The post-
operative course was uneventful and the patient was
discharged 7 days after the surgery.
Figure 6: Intra-operative image showing a trans-mesenteric
hernia with necrotic small bowel (Case 3)
Discussion
Internal hernias are rare and represent between 0.5 and
4.1% of the etiologies of small bowel obstruction [4].
However, this frequency may be underestimated because
they are often asymptomatic. Besides, they can be
diagnosed in post mortem with a frequency between 0.2 and
0.9% [3].
Internal hernias occur through orifices that may be
congenital (abnormalities of bowel rotation or mesenteric
attachments) or acquired (after abdominal surgery or
trauma) [3]. They are classified according to their
topography in three groups [5]:
• Internal hernias through a natural orifice such as the
foramen of Winslow;
• Internal hernias through an abnormal orifice (e.g., trans-
mesocolic, trans-mesenteric);
• Retroperitoneal hernias (e.g., para-duodenal, supra-
vesical) [5].
In our patients, these were internal hernias through an
abnormal orifice including 2 trans-mesenteric and 1 trans-
mesocolic.
Trans-mesenteric hernias account for 8-10% of all internal
hernias and represent a frequent cause of small bowel
obstruction in children (35%) [1]. However, trans-mesocolic
hernias are infrequent [6].
The diagnosis of asymptomatic internal hernias is difficult.
This explains why they are often diagnosed when
strangulation occurs with symptoms of small bowel
obstruction [7]. This was the case in our patients.
Tendeng JN., et al. Surg Chron 2021; 26(3); 319-322.
CT scan has a key role in preoperative diagnosis. It allows a
dynamic evaluation of the intestines and mesentery [1,4].
However, topographic diagnosis is more difficult [8,9]. This
explains why the definitive diagnosis was made
intraoperatively for every patient in our study.
In addition, CT scan was not available at the moment of the
management of our patients. We used plain abdominal
radiography for the diagnosis. It showed signs of small bowel
obstruction in all patients and an exploratory laparotomy
was indicated. To realize an accurate topographic diagnosis
intraoperatively, some landmarks such as the
duodenojejunal flexure, cecum, left colonic flexure and
rectosigmoid junction may help [5,10].
The treatment consists of the reduction of the contents of
the hernia followed by bowel resection with end-to-end
anastomosis if there is intestinal necrosis [11]. Trans-
mesenteric hernias are more frequently associated with
necrosis. In fact, this is due to the absence of a hernial sac
resulting in the strangulation of a longer portion of the small
bowel [3]. Closure of the abnormal orifice is recommended
for trans-mesenteric and trans-mesocolic hernias [11].
However, it should be done with caution to avoid vessel
injury. In our study, bowel resection was necessary for 2
patients and closure of the defect was performed in all
patients. Laparoscopy can be used for treatment, but mostly
for uncomplicated forms [11,12,13].
Conclusion
Strangulated internal hernia is infrequent. The preoperative
diagnosis without CT scan is difficult. Exploratory
laparotomy can confirm the diagnosis and its topography.
The treatment consists of the reduction of the contents
followed by a closure of the defect.
References
1. Mathias J, Bruot O, Ganne PA, Laurent V, Regent D. Internal hernias. EMC
Radiodiagn-Appar Dig. 2008;33-015.
2. Blachar A, Federle MP. Internal hernia: An increasingly common cause of
small bowel obstruction. Semin Ultrasound CT MRI. 1 avr
2002;23(2):174-83.
3. Ghiassi S, Nguyen SQ, Divino CM, Byrn JC, Schlager A. Internal hernias:
clinical findings, management, and outcomes in 49 nonbariatric cases.
J Gastrointest Surg Off J Soc Surg Aliment Tract. mars 2007;11(3):291-
5.
4. Murali Appavoo Reddy UD, Dev B, Santosham R. Internal Hernias:
Surgeons Dilemma-Unravelled by Imaging. Indian J Surg. août
2014;76(4):323-8.
5. Mamadou C, I K, O K, I K, M D, Ao T, et al. Abdominal Internal Hernias; 5
Cases At Aristide Le Dantec Hospital. Internet J Surg [Internet]. 31 Dec
2009 [cited 6 Oct 2018]; 24(2).
6. Bakali Y, Alami S, Majbar M, El Fadili H, Alaoui M, Benamar a, et al. Internal
hernia transmésocolique : a rare cause of intestinal obstruction. J Afr
Hepato-Gastroenterology. 1 Dec 2012;6:249-50.
7. Edwards HM, Al-Tayar H. A transmesenteric congenital internal hernia
presenting in an adult. J Surg Case Rep [Internet]. déc 2013 [cité 5 oct
2018];2013(12). Disponible sur:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3887995/
8. Zissin R, Hertz M, Gayer G, Paran H, Osadchy A. Congenital internal hernia
as a cause of small bowel obstruction: CT findings in 11 adult patients.
Br J Radiol. sept 2005;78(933):796-802.
9. Hamimi AAH, Yunus TE. Internal mimics hernias and their mimics: How
would radiologists help? Egypt J Radiol Nucl Med. 1 déc
2014;45(4):1071-8.
3
 Tendeng JN., et al. Surg Chron 2021; 26(3); 319-322.

10. Akyildiz H, Artis T, Sozuer E, Akcan A, Kucuk C, Sensoy E, et al. Internal 13. Mehran A, Szomstein S, Soto F, Rosenthal R. Laparoscopic repair of an
hernia: Complex diagnostic and therapeutic problem. Int J Surg. 1 janv internal strangulated supravesical hernia. Surg Endosc Interv Tech.
2009;7(4):334-7. 2004 ;18(3) :554–556
11. Hrarat LA, Kotobi H. Surgical treatment of internal hernias. EMC-Tech
Chir-Appar Dig. 2013;29(4):1-13.
12. Antedomenico E, Singh NN, Zagorski SM, Dwyer K, Chung MH.
Laparoscopic repair of a right paraduodenal hernia. Surg Endosc Interv
Tech. 2004;18(1):165–166.

Corresponding author:
Jacques Noël TENDENG 321
General Surgery Department
Saint Louis Regional Hospital
Email: Jacques-noel.tendeng@ugb.edu.sn
Phone: +221 772422492