Abdom Imaging 26:86 – 88 (2001) DOI: 10.1007/s002610000135

Abdominal Imaging © Springer-Verlag New York Inc. 2001

Strangulated transomental hernia: CT findings E. Delabrousse,1 M. Couvreur,1 O. Saguet,1 B. Heyd,2 S. Brunelle,1 B. Kastler1 1

Service de Radiologie A, CHU Jean Minjoz, 3 bvd A. Fleming, 25000 Besanc¸on, France Service de Chirurgie, CHU Jean Minjoz, 3 bvd A. Fleming, 25000 Besanc¸on, France

2

Received: 26 June 2000/Accepted: 12 July 2000

Abstract We report a case of surgically confirmed strangulation of small bowel through a defect in the greater omentum. Computed tomography demonstrated the presence and the location of this very unusual internal abdominal hernia. Those findings are presented. Key words: Transomental hernia—Computed tomography—Internal hernia.

Internal abdominal hernia is defined as the protrusion of a viscus through a normal or abnormal aperture within the confines of the peritoneal cavity [1]. It is an unusual cause of small bowell obstruction. This diagnosis has been principally based on surgical observations. The increasing use of computed tomography (CT) has recently provided preoperative diagnosis of internal abdominal hernia [2, 3]. We report a case of strangulated transomental hernia and present the CT findings. To our knowledge, the CT manifestations of this entity have not yet been reported in the radiologic literature.

Case report An 87-year-old woman was admitted to the emergency room with acute abdominal pain, intermittent nausea, and vomiting. On physical examination, there was diffuse abdominal tenderness but no guarding. Bowel sounds were present on abdominal auscultation. The patient was afebrile. Erect abdominal plain film showed several dilated small bowel loops with air–fluid levels. Laboratory Correspondence to: E. Delabrousse

studies were normal. Because of the suspicion of small bowel mechanical obstruction, abdominal CT was performed. CT showed a cluster of several dilated loops of small bowel in the right paracolic gutter that displaced the ascending colon and cecum medially and posteriorly (Fig. 1A). Small bowel infarction signs including vanished intestinal walls and mesenteric changes were present (Fig. 1B). Collapsed distal ileal loops confirmed the mechanical obstruction (Fig. 1C). The transition zone was found on the medial side of the cluster of small bowel loops. Two loops with a beaklike appearance and their mesentery were shown incarcerated inside an intraperitoneal hernial ring (Fig. 1A). A strangulated internal abdominal hernia was suggested. Surgery demonstrated a strangulated transomental hernia (Fig. 2). Resection of the gangrenous ileal loops, primary anastomosis, and closure of the omental defect were performed. The postoperative course was uneventful.

Discussion Transomental hernia is one of the rarest types of internal abdominal hernias, accounting for approximately 2% of the reported cases [4]. The age at diagnosis is usually older than 50 years [4, 5]. Most occur on the right side of the greater omentum [6]. The omental defect may have a congenital or acquired origin and is usually unique [6 – 8]. No sac is ever found and the entire hernia is always intraperitoneal [9]. In general, the strangulated viscus is the small bowel [4]. In these cases, the clinical presentation is that of an intestinal obstruction. In few cases is a correct preoperative diagnosis of internal abdominal hernia made [10, 11]. However, due to increased use of CT in acute abdomen and its superior resolution compared with abdominal plain radiography and barium enema, this preoperative diagnosis should be more frequent. To our

E. Delabrousse et al.: CT findings of transomental hernia

87

Fig. 1. A Contrast-enhanced CT shows a cluster of ileal loops (arrowheads) in the right paracolic gutter that displaces the ascending colon medially and posteriorly (large arrow). Note the presence of two small bowel loops with a beaklike appearance (arrows) incarcerated with the mesentery (white star) inside an intraperitoneal hernial ring. B Small bowel infarction signs including vanished intestinal walls (arrowheads)

and mesenteric changes (white star) are present. C Dilated fluid-filled proximal small bowel loops (arrows) and collapsed distal small bowel loops (arrowheads) confirm mechanical obstruction.

knowledge, the CT appearance of transomental hernia has not been reported in the radiologic literature. In our case, CT findings of strangulated transomental hernia included (a) a cluster of dilated loops of small bowel in the right paracolic gutter, (b) intestinal infarction signs, (c) displacement of the ascending colon and the cecum medially and posteriorly, (d) dilated air–fluidfilled small bowel loops proximal and in the cluster of

loops, and (e) two loops of small bowel with a beaklike appearance incarcerated with their mesentery inside an intraperitoneal hernial ring. We think that this combination of CT findings is diagnostic of strangulated transomental hernia. Radiologists should be aware of these CT findings. Recognition of the appearance of strangulated transomental hernia by CT may lead to an appropriate surgical treatment early on.

Fig. 2. Schematic representation of the hernia of several ileal loops through a defect on the right side of the greater omentum.

88 Acknowledgments. We thank Florence Lignon and Michele Rosen for their help in preparation of the manuscript.

References 1. Meyers MA. Internal abdominal hernias. In: Meyers MA, ed. Dynamic radiology of the abdomen: normal and pathologic anatomy, 2nd ed. New York: Springer-Verlag, 1982 2. Harbin WP. Computed tomographic diagnosis of internal hernia. Radiology 1982;143:736 3. Hoeffel JC, Zimberger J, Pocard B, et al. Demonstration by computed tomography of a case of internal small bowel herniation. Br J Radiol 1992;66:1045–1046 4. Hull JD. Transomental hernia. Am Surg 1976;42:278 –284

E. Delabrousse et al.: CT findings of transomental hernia 5. Watt PC. Transomental hernia causing intestinal obstruction in an elderly patient. Postgrad Med J 1983;59:790 6. Jamart J, Guillemin F, Boissel P, et al. Hernies trans-e´piploı¨ques. Lyon Chir 1980;76:49 –50 7. Siddins MT, McGowan K. Transomental herniation mimicking sigmoid volvulus. Aust N Z J Surg 1990;60:133–135 8. Leissner KH. Transomental strangulation. A rare cause of an internal hernia. Acta Chir Scand 1976;142:483– 485 9. Versaci A, Rossito M, Pante S, et al. Su di un caso di ernia transomentale strozzata. G Chir 1999;20:487– 489 10. Takagi Y, Yasuda K, Nakada T, et al. A case of strangulated transomental hernia diagnosed preoperatively. Am J Gastroenterol 1996;91:1659 –1660 11. Iuchtman M, Berant M, Assa J. Transomental strangulation. J Pediatr Surg 1978;13:439 – 440