Transmesenteric hernia caused by mesenteric defects are rare causes of intestinal obstruction in children. Here, we report a rare mesenteric defect, which was completely mesenteric in absence, with the defect extending from the mesenteric root to the ascending colon.

A 4-year-old Han Chinese boy presented to the surgical emergency department with a 1-day history of abdominal pain and vomiting. An X-ray examination of the abdomen revealed intestinal obstruction. The patient was diagnosed with intestinal obstruction and was advised to undergo laparoscopy. Laparoscopy revealed a large mesenteric defect, with the defect extending from the mesenteric root to the ascending colon, and a single mesenteric vessel supplied the small intestine. The single mesenteric vessel passed along the small intestine and crossed with the distal ileum, which trapped the distal ileum, leading to intestinal obstruction. During surgery, the distal ileum was transected and reanastomosed in front of the mesenteric vessel to relieve the intestinal obstruction, and the mesenteric defect was closed to prevent mesenteric hiatal hernia. There was no recurrence of intestinal obstruction during the follow-up.

A complete mesenteric defect with ileal volvulus is a rare cause of intestinal obstruction. Prompt exploration based on clinical signs is mandatory to establish the diagnosis and provide immediate therapy. This can reduce morbidity and mortality in this rare life-threatening disease.

Transmesentric hernias are a type of internal hernia, in which there is herniation of bowel loops through a defect in the mesentery. They present with a wide variety of symptoms without any specific radiological features, leading to a delay in diagnosis and high mortality rate. Here, we present a case series of four patients with this rare but fatal cause of small bowel obstruction. Three children presented to the emergency department with small bowel obstruction. The other baby was a preterm neonate with an antenatal scan showing small bowel obstruction. All children underwent emergency laparotomy and were found to have a mesenteric defect with herniation and gangrene of the small bowel. Resection anastomosis of the gangrenous segment and closure of the mesenteric defect were done. The differential for small bowel obstruction in children should include transmesentric hernia. Laboratory or imaging investigations are often inconclusive. Timely exploration can save lives in this rare but life-threatening condition.

In this report, we discuss the case of an 11-year old girl presenting with acute abdominal pain caused by gangrene of a large part of the small bowel. During urgent surgical exploration, the cause of gangrene appeared to be herniation of the small bowel through a congenital defect in the mesentery with subsequent strangulation. A resection was performed leaving the patient with only 130 cm of small bowel remaining. Transmesenteric hernia is a rare type of internal herniation consisting of a small congenital defect in the small bowel mesentery through which the intestine can herniate and subsequently become strangulated. We present a case of transmesenteric hernia with disastrous effects and review the literature regarding this rare type of hernia.

A three-year-old boy with mild symptoms of an upper respiratory tract infection and recent onset vomiting collapsed at home. Resuscitative attempts in hospital were eventually unsuccessful. At autopsy an obstruction of the small intestine, with ischemia, was identified. It had been caused by strangulation of the small intestine through a congenital mesenteric defect. Moderate mesenteric lymphadenopathy, with enlarged lymph nodes in the region of the herniated small intestine, were associated with positive testing for human metapneumovirus and enterovirus. Transmesenteric hernias are a very rare form of internal herniation that have the highest risk of strangulation. Unfortunately in children the presentation may be relatively nonspecific with a precipitate decline towards the end. In the reported case it is possible that mesenteric lymphadenopathy may have contributed to intestinal entrapment by preventing spontaneous reduction.

Internal hernia through a mesenteric defect, called mesenteric hernia, is an uncommon cause of acute intestinal obstruction in newborns. Strangulated mesenteric hernia results in intestinal necrosis or perforation and progressive deterioration with fatal outcome, especially when it occurs in low-birthweight infants. We report two very low-birthweight (VLBW) infants, who presented with acute intestinal obstruction related to mesenteric defect. The initial diagnosis was meconium obstruction in those cases, which is a common cause of bowel obstruction occurring in VLBW infants. Correct diagnosis of mesenteric hernia was difficult in these cases because of rapid deterioration and non-specific radiological findings. Awareness of the possibility of rare mesenteric hernia causing acute intestinal obstruction and surgical intervention in an appropriate timeframe are important for rescuing VLBW infants with such organic abnormalities.

Internal herniation is a rare cause of intestinal obstruction, especially in the emergency department. We report a child with acute abdomen resulting from transmesenteric internal herniation of the small bowel. Radiographic findings revealed gaseous distension of the bowel loops in the upper abdominal area with a paucity of gas in the lower abdomen. Operative finding showed gangrenous small bowel due to mesenteric defect with an internal herniation. The gangrenous bowel was resected and the patient was discharged with an uneventful outcome. We emphasize that early recognition of internal herniation warrants further evaluation and appropriate management.

Congenital mesenteric defects are rare causes of bowel obstruction. Even rarer are mesenteric defects with an apple peel type of deformity, probably described definitively only once previously. We present a case of a 3 year old boy who presented with a septic-like picture of severe metabolic acidosis and lethargy from a bowel obstruction with bowel ischemia. At laparotomy he was found to have bowel infarction due to herniation through a congenital mesenteric defect with an apple peel type of deformity of the bowel without bowel atresia.

We report a unique case of transmesenteric hernia resulting in death, which went undiagnosed during a recent hospital visit. The victim was a 2.5-year-old girl who - with the exception of chronic constipation - had no medical history. One night she complained of abdominal pains and was taken to a pediatric hospital where doctors performed an abdominal X-ray and echography. No significant findings suggesting bowel obstruction (e.g. air-fluid levels or dilation of the bowel) were obtained on examinations and bloody feces were not observed in this particular episode. As her abdominal pain gradually attenuated, the doctor allowed her to return home. A few hours later, she lost consciousness and expired despite resuscitation efforts attempted at an emergency hospital. A subsequent autopsy revealed that the small bowel had herniated through a defect in the mesentery resulting in two consecutive and inversely forming loops, in which each loop protruded on either side of the mesentery. This rare morphological anatomy seems to have progressed in a two-step process. The girl's mild abdominal pain was likely induced by herniation and formation of the first intestinal loop, followed by severe shock occurring when the subsequent intestinal segment invaginated into the same defect forming the second loop on the opposite side of the mesentery. This case illustrates the difficulty of diagnosing transmesenteric hernia due to the presentation of unspecific symptoms; especially in infants and toddlers. Furthermore, this report demonstrates the value of a complete autopsy in cases of sudden and unexpected deaths involving children.

Internal hernias are uncommon in children and their clinical and imaging findings have not been widely addressed.

To determine the spectrum of clinical and imaging findings of internal hernia (IH) in children and to highlight diagnostic features.

Review of clinical, imaging and surgical findings in 12 children with surgically proven IH.

IH found in seven girls and five boys. Five of the children were neonates and seven were between ages 8-17 years. All neonates presented acutely and had transmesenteric internal hernias (TMIH) (four congenital, one acquired). In the older children, five presented with chronic symptoms and two presented with acute symptoms; the former had paraduodenal hernias (all congenital) and the latter had a congenital pericecal and an acquired TMIH. Only 2/5 neonatal TMIH could be appreciated on GI contrast examination. All five paraduodenal hernias were easily diagnosed on UGI series. CT, in two older children, depicted a paraduodenal hernia and the acquired TMIH. In 7/10 (70%) congenital IH, there was associated malrotation (in all four right paraduodenal hernias).

There is a wide spectrum of clinical and imaging findings of IH in children. TMIH were difficult to appreciate on GI contrast examinations, but paraduodenal hernias were easy to appreciate. One must have a high index of suspicion for right paraduodenal hernia if UGI series shows duodenum and proximal small bowel to the right of the spine.

Altered mental status can have many causes, some of which are life threatening, especially in children. In addition to the usual central nervous system and metabolic causes, such as meningitis, encephalitis, seizure, electrolyte imbalance, and inborn errors of metabolism, some less common causes of altered mental status, which if not diagnosed and managed rapidly, can have poor consequences. We present a case of a child with a life-threatening unusual cause of altered mental status, a mesenteric hernia with hypovolemic shock. The hernia was reduced successfully at laparotomy. The postoperative course was uneventful.

Intestinal obstruction is a common surgical emergency. Transmesenteric hernia is an unusual cause of bowel obstruction that may result in irreversible damage of the bowel and a fatal outcome. Once incarceration of the bowel occurs, strangulation and gangrene follow immediately. The mortality rate associated with this condition is about 15%, but in the presence of gangrene of the bowel, the mortality rate is more than 50%. An accurate preoperative diagnosis of a transmesenteric hernia is very difficult and rarely made. Therefore, in patients with small bowel obstruction, in the absence of a history of previous surgery to suggest adhesions or an external hernia, the possibility of a transmesenteric hernia must be considered. We describe a case with gangrene of a long segment of the small bowel caused by a transmesenteric hernia through a large defect of small bowel mesentery in a child.

Gastrointestinal causes of sudden and/or unexpected death in the young are uncommon and only rarely involve congenital anomalies of the mesentery. Two cases are reported of unexpected deaths following herniation of intestine through congenital mesenteric defects to illustrate the forensic issues that may arise. Case 1 involves a 2.5-year-old girl who collapsed on arrival to hospital following 18 hours of fever and apparently mildly nonspecific symptoms. Resuscitation was unsuccessful, and at autopsy a segment of gangrenous small intestine was found that had herniated through a congenital mesenteric defect. Case 2 involves a 23-year-old woman with a past history of severe mental and physical disabilities who was found dead in her bed. She had a recent history of mild diarrhea and vomiting, but had not appeared particularly ill. At autopsy the peritoneal cavity was filled with a very dilated and obstructed colon as a result of herniation of a segment of sigmoid colon through a distal small intestinal mesenteric defect. These cases demonstrate that symptoms and signs of intestinal ischemia may not be clearly manifested in early childhood and that developmental delay may also result in older individuals presenting in a nonspecific manner. Although rare, congenital mesenteric abnormalities with compromise of the intestinal vasculature remain a possibility to be considered at autopsy in all cases of unexpected death, despite the lack of a clear history of significant gastrointestinal disturbance. Death may relate to ischemic compromise of either the herniated portion of intestine (as in case 1) or to the stretched intestine bordering the hernial orifice (as in case 2).

A mesenteric hernia is one type of intraperitoneal hernia. There is no hernia sac in this situation but only a mesenteric defect, which is present at birth. Strangulated mesenteric hernia is a rare cause of intestinal obstruction especially in the pediatric population. Between January 1996 and January 2006, four patients with intestinal obstruction were determined to have congenital mesenteric hernia at Chang Gung Children's Hospital. Patients consisted of three boys and one girl, ranging in age from 2 years 5 months to 5 years 4 months. All patients presented with symptoms and signs indicative of intestinal obstruction. On physical examination, all patients appeared to be severely ill. A shock-like state was associated with necrosis of the strangulated bowel in two patients. A palpable abdominal mass was present in one patient with volvulus of small bowel. The plain abdominal radiography and the ultrasound scan also showed dilatation of the small bowel and excluded intussusception. All the patients underwent laparotomy after initial resuscitation. During laparotomy, three patients had incarceration of small bowel through the small mesenteric defect, and another one had volvulus with gangrenous bowel entrapped within a large mesenteric defect. The defects ranged in size are from 2 to 7 centimeters in diameter. Simple reduction of the incarcerated bowel with repair of the defect was performed in two patients, resection of gangrenous bowel and primary anastomosis was required in one patient, and resection with end ileostomy was needed in another one patient. There was no postoperative mortality in our patients.

A mesenteric hernia is a rare cause of intestinal obstruction, especially in children. Open exploration is the only way to establish a clear anatomic diagnosis.

The Treves' field congenital hernias (TFCH) are an unusual cause of bowel obstruction that may result in irreversible damage of the small bowel or a fatal outcome, unless treated timely and properly. We analyzed retrospectively the medical records of four patients who underwent surgery for TFCHs over a period of 9 years. The types of TFCHs, only diagnosed at surgery, were identified as transmesenteric through a defect in Treves' field in three patients, and as hernia into Treves' field pouch in one patient. Patients had non-specific clinical manifestations, and imaging findings demonstrated only small bowel obstruction. Delay in accurate preoperative diagnosis, and especially patient-related delay, led to a primary enterectomy-anastomosis for necrotic small bowel in the patients with transmesenteric hernias. One infant with necrotic bowel died postoperatively. It may be difficult to diagnose TFCHs in children preoperatively. Misdiagnosis of bowel obstruction caused by this type of internal hernia might lead to small bowel necrosis or death. The risk of this complication seems to be more influenced by pre-hospital delay. Awareness of the severe consequences of delay in diagnosis, high clinical suspicion, early recognition, and proper surgical intervention are essential in the successful management of TFCHs.