An Unusual Case of Right Transmesocolic Hernia with Ureter at the Neck of Sac

doi:10.4236/ss.2011.26073

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Surgical Science, 2011, 2, 341-343

doi:10.4236/ss.2011.26073 Published Online August 2011 (http://www.SciRP.org/journal/ss)

An Unusual Case of Right Transmesocolic Hernia with

Ureter at the Neck of Sac

Mahendra Singh Gond, Arjun Saxena, Pawan Agarwal, Uday Somashekar, Dhananjaya Sharma*

Department of Surgery, Gove rnment NSCB Medical C ol le ge , Jabalpur, India

E-mail: [email protected]

Received March 5, 2011; revised May 17, 2011; accepted June 20, 2011

Abstract

The purpose of the present article is to present an unusual case of internal herniation. In this case small bowl

obstruction was due to congenital right trans-mesocolic hernia which had the right ureter at the neck of the

sac forming a constriction band. This requires careful widening of neck of hernia, so as to avoid iatrogenic

trauma to ureter. This unusual presentation needs dissemination as this type of internal hernia is extremely

rare.

Keywords: Hernia, Abdominal/Surgery, Intestinal Obstruction/Etiology/Surgery, Mesocolon/Pathology/

Surgery

1. Introduction

Internal hernia is a rare cause of intestinal obstruction

with a reported incidence of less than 1% [1-3]. Its pres-

entation is usually non-specific. Key to its successful

operative management is to safeguard the important vas-

cular structures like superior mesenteric artery and infe-

rior mesent eric vein, etc whic h course t hrough the neck of

these hernias [4]. In this case report we present an unusual

case of a congenital right transmesocolic hernia with

small bowel obstruction which had right ureter at the

neck of the sac forming a constriction band. Right

ureter has not been reported near the neck of any internal

herniation; which makes dissemination of this unusual

and rare presentation important, so inadve rtent iatrogenic

trauma can be avoided to this important structure.

2. Case Report

A 35 year old male was admitted in the surgical ward

with acute abdominal pain and vomiting. He had a his-

tory of similar self limiting episodes in the last 5 years.

There was no history of previous abdominal surgery.

Abdominal examination revealed generalised abdominal

distension, with sluggish bowel sounds; guarding and

rigidity were absent. General parameters and routine

blood investigations were normal. Plain abdominal x-ray

showed multiple air fluid levels (Figure 1). Ultrasono-

graphy showed dilated bowel loops, with to and fro mo-

tion. The patient did not improve with 48 hours of con-

servative treatment and was then taken up for explora-

tory laparotomy.

Mid line vertical laparotomy was done. A defect of 5

cm diameter was found in the mesentery of ascending

colon. The entire small gut except th e proximal 15 cm of

jejunum and terminal ileum had herniated through the

Figure 1. Scout film abdomen in upright position showing

multiple fluid levels.

M. S. GOND ET AL.

342

defect and was contained behind the ascending colon

creating a retroperitoneal bulge. The caecum and as-

cending colon were mobilised after incising the perito-

neal fold along the ascend ing colon. The herniated small

bowel was viable but congested. A tubular structure was

found in the neck of hernia sac, which on closer inspec-

tion was determined to be the right ureter (Figures 2 and

3). In order to avoid injury to ureter and to widen the

neck and to relieve the obstruction, mesocolic defect was

widened in the caudal direction, avoiding superior mes-

enteric vessels on the medial side. There after the herni-

ated loops were pulled back into the peritoneal cavity

and the defect was closed by suturing the margins of the

defect to the retro peritoneum. The postoperative recov-

ery was uneventful.

3. Discussion

Internal hernias are defined as protrusion of a viscus

Afferent

loop

Efferent

loop

Ri g h t 

Ureter

De fe c t

Figure 2. Operative photograph showing right ureter the

neck of hernia sac.

Figure 3. Diagrammatic representation of operative finding

showing right ureter the neck of hernia sac.

through a normal or abnormal peritoneal or mesenteric

aperture within the confines of the peritoneal cavity. The

orifice can be either acquired, such as a postsurgical,

traumatic, or postinflammatory defect, or congenital,

including both normal apertures, such as the foramen of

Winslow, and abnormal apertures arising from anomalies

of internal rotation and peritoneal attachment [1]. With

more new surgical procedures being performed using a

Roux loop, the number of transmesenteric, transmeso-

colic, and retroanastomotic internal hernias are increas-

ing [5].

Preoperative clinical diagnosis of internal hernia is ex-

tremely difficult because of the nonspecific clinical

presentation [6]. Ultrasonography and Computed Tomo-

graphy are helpful with observation of a saclike mass or

cluster of dilated small bowel loops at an abnormal

anatomic location [7,8].

Internal herniation through right mesocolon is ex-

tremely rare, with very few ca ses having been rep orted [9,

10]. Surgeons are taught to keep important vascular

structures in mind when incising the neck of internal

hernia; e.g. inferior mesenteric vein and ascending left

colic artery (left paraduodenal hernia), superior mesen-

teric artery (right paraduodenal hernia) and portal traid

(foramen of Winslow hernia). In the present unusual case

small bowel loops migrated through a congenital defect

in the mesentry of ascending co lon to come to lie behind

the ascending colon. There was no malrotation as evident

by normal location of the duodeno-jejunal and ileocecal

junctions. The right ureter located in the anterior edge of

such a mesocolic defect is susceptible to injury if it is not

identified and protected while incising the edges to re-

lease the entrapped bowel.

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