An unusual cause of small bowel obstruction: “The swiss cheese transomental hernia”

Abstract

A 30-year-old female patient suffering from abdominal pain, nausea, vomiting and dyspeptic complaints over the past 2 days was admitted to our emergency department.process. The pain was associated with biliary vomiting. On physical examination, the temperature was normal. Her abdomen was distended with mild tenderness over the umbilical and epigastric areas. There was no surgical scar, no abdominal wall hernia and no abdominal mass.

A spontaneous transomental hernia through the greater omentum

“…Hernia defect is congenital or acquired, post-traumatic, secondary to intraperitoneal inflammatory disease or due to the appearance of area of weaknesses related to age in the greater omentum. In few cases the patient is young without any surgical or traumatic history and free from any inflammatory disease of the peritoneum, in this exceptional case the TOH is spontaneous [ 3 – 7 ]. Diameter of the defect on the greater omentum varies from 2 to 10 cm [ 3 , 6 ], through which protrudes a part of the small bowel or occasionally another free segment of intestine as cecum or sigmoid colon [ 3 , 6 ].…”

“…Clinical manifestations are unspecific causing diagnosis delay [ 2 ]. Patients describe recurrent and ambiguous symptoms, combining paroxysmal abdominal pain, nausea, bloating and constipation that disappear spontaneously [ 3 , 4 , 7 ]. In more acute and irreversible forms the patient consults for AIO which is the manifestation of complicated form [ 1 , 4 , 6 ].…”

“…Complicated internal hernias represent less than 1% of all the AIO [ 1 , 3 ], radiography of the abdomen made in this emergency circumstances shows nonspecific central and small air-fluid level caused by the small bowel obstruction. In rare cases an abnormal position of a small air-fluid which is the consequence of an abnormal protrusion of the small bowel is viewed [ 7 ]. Modern imaging represented by abdominal multidetector computed tomography (CT) allows in 16% of cases the diagnosis of TOH [ 5 ], by viewing the passage of mesenteric vessels through the greater omentum with a stretched loop in an abnormal position in the right paracolic gutter when the defect interests the greater omentum [ 6 ], or an abnormal bowel loops retropositioned between the stomach and the pancreas when the defect interests the gastro-colic ligament [ 5 ].…”

“…Treatment of TOH is surgical, approached by laparoscopy or laparotomy [ 7 ], the herniated bowel must be reduced [ 1 , 6 ], and the omental defect has to be closed to prevent recurrences [ 1 , 7 ], section of the greater omentum from its free edge to the abnormal defect is an alternative [ 6 ]. Total omentectomy is performed if exploration shows pathological greater omentum [ 1 , 7 ]. In case of intestinal necrosis, bowel resection is necessary with respect for traditional rules of digestive continuity restoration [ 1 ].…”

“…Even the advances in imaging technics, diagnosis of this disease remains difficult and it is still often made during the operative time [ 3 , 5 , 6 ]. Transomental internal hernia (TOH) is the rarest type, and represents 1 to 4% of the IH [ 1 , 3 , 5 , 7 ]. It interests mostly the greater omentum and exceptionally the gastrocolic ligament or the lesser omentum [ 1 ].…”