Case reports
Acta chir belg, 2005, 105, 653-655
Transmesosigmoid Hernia : Report of a Case and Review of the Literature
G. Van der Mieren, C. de Gheldere, P. Vanclooster
Department of General Surgery, Heilig Hart Ziekenhuis, Lier, Belgium.
Key words. Internal hernia ; transmesosigmoid hernia ; postpartum ; intestinal obstruction.
Abstract. We report a case of a transmesosigmoid hernia in a 6 weeks postpartum woman. We found 14 previous reports
of this rare type of internal hernia. Our patient presented with acute abdominal pain and developed a small intestinal
obstruction. History, clinical and radiographic examination were not diagnostic. An early laparoscopy was performed
and a herniation of a small intestine loop through a hole in the sigmoid mesocolon was seen. The hernia was reduced
and the defect in the sigmoid mesocolon was closed laparoscopically. The small intestine was viable and enterectomy
could be avoided. The role of laparoscopy and potential causes of this type of hernia are discussed.
Case report
A 33-year old woman presented to the emergency
department with acute abdominal pain, 6 weeks after an
uneventful pregnancy and delivery (gravida 3, para 2,
abortus 1) and without previous history of surgery or
trauma. The pain was colicky and started only 2 hours
before, during defaecation. The patient had a marked
urgency to move and was nauseous. She vomited once.
She had no mictalgy. At time of arrival, her temperature
was 37°C, the blood pressure was 130/85 mmHg and the
pulse rate 77 bpm. Abdominal palpation revealed
marked tenderness in the left fossa iliaca, the hypogastric region and mild tenderness in the right fossa iliaca,
but there were no peritoneal signs. At auscultation there
was hypoperistalsis. She had no flank pain. Rectal
examination was normal.
Laboratory findings were normal, except for a mildly
increased leucocytosis : 10.100 WBC/mm3 (normal
< 10.000) and CRP : 1,1 mg/dl (normal < 0,7 mg/dl).
Urine analysis showed 29 RBC/µl and 36 WBC/µl (both
normal < 25/µl). Plain abdominal X-ray showed faecal
residus over the whole abdomen but no air-fluid levels.
An enhanced CT-scan with rectal and intravenous
contrast was performed. This showed an enlarged uterus
without signs of inflammation, correlating with the
6 weeks postpartal state. There was distention of the
jejunum and proximal ileum but no definite obstructive
problem could be established (Fig. 1).
Because there were no signs of severe intraabdominal
disease at admission and because no definite explanation
for the acute abdominal pain was found, the patient was
hospitalized and observed. A symptomatic treatment
with intravenous non narcotic analgetics and antiemetics
was started.
Fig. 1
Enhanced CT-scan : distension of the jejunum and proximal
ileum but not definitive obstructive problem.
After 12 hours of conservative treatment, the pain did
not subside. She vomited several times and there was no
passage of stool or flatus in the 12 hours of observation.
Furthermore, the clinical reevaluation revealed peritoneal signs : during palpation, the patient showed definite rebound tenderness in the left iliac fossa and the
hypogastric region. A laparoscopy was performed. Mild
distension of the small intestine was seen. Following the
small intestine from distal to proximal, a herniation of
50 cm ileum was seen through a defect in the sigmoid
mesocolon. The defect was 3 cm in diameter and distal
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of the inferior mesenteric artery. A cautious and complete reduction of the herniated intestine was performed.
The margins of the defect were very irregular and
ragged. There seem to be an avulsion of the sigmoid
mesocolon with local denudation of the retroperitoneum
left laterally at the fusion line between the visceral and
parietal peritoneum. The defect was closed laparoscopically with running sutures of Vicryl 2/0. The incarcerated intestinal loops showed to be viable. No enterectomy
was performed.
The postoperative course was uneventful. The patient
left the hospital on the second postoperative day in
general good health. At follow-up examination, three
weeks later, the patient was completely free of complaints and had resumed all her normal activities.
Discussion
In surgical practice, external hernias and postoperative
adhesions are the main causes of intestinal obstruction.
Consideration of internal herniation is mandatory in the
absence of external herniation and without history of
previous abdominal surgery (1). The incidence of small
bowel obstruction due to internal hernias ranges from 1
to 3% of all intestinal obstructions (1-2). More common
types are paraduodenal, paracaecal, transomental,
mesenteric defects and hernias through the foramen of
Winslow. About 5% of all internal hernias involve the
sigmoid mesocolon (1, 3). BIRCHER & STUART (1)
described 3 types of hernia involving the sigmoid mesocolon. Intersigmoid hernia arises in the congenital fossa
located in the attachment of the lateral aspect of the sigmoid mesocolon to the posterior abdominal wall (fossa
intersigmoideus). A transmesosigmoid hernia occurs
when loops of intestine pass through a defect in the
sigmoid mesocolon, as occurred in our patient. The
intrasigmoid hernia occurs when the defect in the
sigmoid mesocolon affects only the left leaf of the
peritoneum and the hernia sac lies within the sigmoid
mesocolon itself (1).
We found 14 previous reports of transmesosigmoid
hernia (1-7).
There is one report of transmesosigmoid hernia
during pregnancy (4). Our patient was 6 weeks postpartum. To our knowledge, it is the first report of this
type of hernia in the immediate postpartum course.
There is little known about the aetiology of idiopathic
defect in the mesentery. There are a few hypotheses
available. FEDERSCHMIDT stated that the defects represented a partial regression of the dorsal mesentery in the
human being. MENEGAUX postulated that fenestration
occurred during the developmental enlargement of an
inadequately vascularized area. JUDD, KIEBEL & MALL
believed that because the greater part of the gut is displaced from the abdominal cavity into the umbilical cord
G. Van der Mieren et al.
in fetal life, considerable pressure might cause the colon
to continue along the path of least resistance and gradually force its way through the delicate structure of the
mesentery (8).
These aetiological hypotheses postulate a congenital
cause. PEREZ ROUIZ et al. (6) described a transmesosigmoid hernia due to pneumoperitoneum during previous
laparoscopic surgery.
BERTHET & ASSADOURIAN (2) postulated that fixation
of the sigmoid and small intestine due to adhesions and
traction on the meso in an inguinal hernia, could cause
an internal hernia. KING (9) described also a theory that
peritoneal inflammation followed by adhesions and
fibrosis could cause mesenteric defects.
Little information is also available about the characteristics of mesenteric defects. Most of the defects are 2
to 4 cm in diameter (3-5). SASAKI et al. (3) described the
area around the defective mensentery as thin and weak.
GULLINO et al. (10) described the defect as a fissure with
sclerosed border, and YIP et al. (5) as rounded and
usually located immediately above the superior haemorrhoidal vessel.
In our case, the origin of the defect remains unknown.
The morphological characteristics of the defect suggested a traumatic cause but there was no history of previous
surgery or trauma. Because our patient was 6 weeks
postpartum, the defect in the mesocolon was ragged and
irregular, and because there seemed to be a concomitant
partial avulsion at the fusion line between parietal and
visceral peritoneum, we suggest that the mesosigmoid
could have been adherent to the uterus. The hole could
have been torn in the mesosigmoid by traction of the
shrinking uterus.
Surgical treatment is the cornerstone of all internal
hernias. Transmesosigmoid hernias have a natural evolution to strangulation and necrosis of the herniated
structures. In the majority of cases, partial resection of
small intestine is necessary (3).
We want to stress the essential diagnostic and potentially therapeutic role of laparoscopy for these types of
hernia. Timing of the laparoscopy is also very crucial (4,
8). When clinical diagnosis of intestinal obstruction has
been established, abdominal wall hernias excluded, and
there is no previous history of surgery, a diagnostic
laparoscopy should be performed. Immediate action is
necessary in case of peritoneal signs or when investigations fail to identify a specific cause for the obstruction.
Our patient presented with acute abdominal pain
without peritoneal signs and therefore a symptomatic
treatment with non narcotic analgetics was initiated.
After 12 hours, there was no passage of stool or flatus
and the diagnosis of intestinal obstruction was done.
Because our investigations had not identified the reason
for this obstruction, the pain had not subside with the
symptomatic treatment, and because the patient had
Transmesosigmoid Hernia
developed peritoneal signs, a laparoscopy was performed.
An early diagnostic laparoscopy can avoid necrosis
and enterectomy, as in our case.
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7.
8.
9.
References
1. BIRCHER M. D., STUART A. E. Internal herniation involving the
sigmoid mesocolon Dis colon Rectum, 1981, 24 : 404-6.
2. BERTHET B., ASSADOURIAN R. Une forme rare d’hernie interne :
l’hernie du mesocolon sigmoïde. J Chir (Paris), 1993, 130 : 170-2.
3. SASAKI T., SAKAI K., FUKUMORI D. et al. Transmesosigmoid hernia :
report of a case. Surg Today, 2002, 32 : 1096-8.
4. JOHNSON B. L., LIND J. F., ULICH P. J. Transmesosigmoid hernia
during pregnancy. South Med J, 1992, 85 : 650-2.
5. YIP A. W., TONG K. K., CHOI T. K. Mesenteric hernia through
defects of the mesosigmoid. Aust N Z J Surg, 1990, 60 : 396-9.
6. PEREZ ROUIZ L., GABARELL OTO A., CASALS GARRIGO R. et al.
Intestinal obstruction caused by internal transmesosigmoid
10.
hernia.: a complication of laparoscopic surgery ? Minerva Chir,
1997, 52 : 1109-12.
YU C. Y., LIN C. C., YU J. C. et al. Strangulated transmesosigmoid
hernia : CT diagnosis. Abdom Imaging, 2004, 29 : 158-60.
JANIN Y., STONE A. M., Wise L. Mesenteric hernia. Surg Gynecol
Obstet, 1980 , 150 : 747-54.
KING E. S. J. Intestinal obstruction through a mesenteric hiatus.
Br J Surg, 1935, 22 : 504-6.
GULLINO D., GIORDANO O., GULLINO E. Internal hernia of the
abdomen. Apropos of 14 cases. J Chir (Paris), 1993, 130 : 179-95.
C. de Gheldere
Department of General Surgery
Heilig Hart Ziekenhuis
Kolveniersvest 20
2500 Lier, Belgium
Tel.
: +32 3.491 28 62
Fax
: +32 3 491 27 32
E-mail : c.degheldere@skynet.be