Published online Sep 16, 2026. doi: 10.12998/wjcc.126834
Revised: September 7, 2026
Accepted: September 16, 2026
Published online: September 16, 2026
Processing time: 35 Days and 13.4 Hours
Internal hernia is an uncommon cause of mechanical small bowel obstruction, accounting for 0.5%-5.8% of cases. Reported mortality is > 50% when strangulation occurs and treatment is delayed. The diagnosis is easily overlooked because the clinical presentation is indistinguishable from other mechanical causes of obstruction and preoperative imaging findings are often nonspecific. This paper reports a transmesocolic internal hernia through a defect in the transverse mes
A 62-year-old woman presented with 4 days of colicky abdominal pain and repeated vomiting, with obstipation for the preceding 2 days. She had been managed at another hospital for approximately 48 hours with nasogastric de
Internal herniation should be considered early when mechanical obstruction persists despite decompression and no cause is evident on imaging; laparoscopy provides both diagnosis and definitive repair.
Core Tip: Transmesocolic herniation through a defect in the transverse mesocolon is a rare cause of small bowel obstruction that is easily overlooked before operation. In this patient, contrast-enhanced computed tomography localized an abrupt distal jejunal transition point without signs of ischemia, but the underlying cause was established only during the surgery. Emergency diagnostic laparoscopy on the night of admission allowed the herniated jejunum to be reduced, viability confirmed, and the mesocolic defect closed primarily, avoiding resection. Early exploration and a minimally invasive approach provided diagnosis and definitive treatment in a single procedure.
- Citation: Joshi M, Jha S, Jha S, Jhawar N. Laparoscopic treatment of a transmesocolic internal hernia causing small bowel obstruction: A case report. World J Clin Cases 2026; 14(26): 126834
- URL: https://www.wjgnet.com/2307-8960/full/v14/i26/126834.htm
- DOI: https://dx.doi.org/10.12998/wjcc.126834
An internal hernia is the protrusion of a viscus, most often the small bowel, through a congenital or acquired aperture within the peritoneal cavity, so that the herniated segment lies in an abnormal compartment. Internal hernias account for 0.5%-5.8% of all cases of mechanical intestinal obstruction, and the mortality rate exceeds 50% in some series when strangulation occurs and treatment is delayed[1]. As the neck of the defect is often narrow and unyielding, closed-loop obstruction, venous congestion, and transmural ischemia can develop rapidly, and the interval between a benign-looking presentation and irreversible bowel loss may be brief[1,2].
Internal herniation warrants particular attention whenever mechanical obstruction is demonstrated but no cause is identified on preoperative imaging, because the operative thresholds derived from adhesive obstruction cannot be applied uncritically to an obstruction of unexplained mechanism[3,4]. Preoperative recognition is difficult as the clinical syndrome is indistinguishable from other mechanical causes and the reported computed tomography (CT) signs of internal herniation such as clustering or saccular grouping of dilated loops in an abnormal location and crowding, engorgement, or swirling of mesenteric vessels are subtle, inconsistent, and depend on the reader’s index of suspicion[1,5]. Contrast-enhanced CT is nonetheless the imaging modality of choice, primarily because it localizes the transition point and identifies the features of strangulation that mandate immediate operation[6].
This report describes the case of a 62-year-old woman in whom jejunal loops had herniated through a defect in the transverse mesocolon and in whom emergency diagnostic laparoscopy provided both the diagnosis and definitive repair.
A 62-year-old woman presented to the emergency department with colicky abdominal pain and repeated vomiting of 4 days’ duration, with absolute constipation for the preceding 2 days.
The abdominal pain began on the first day of the illness, while the patient was travelling. The pain was colicky and periumbilical, accompanied by repeated vomiting and a complete loss of appetite. Two days before presentation, she was admitted to another hospital, where a 16 Fr nasogastric tube was placed. The aspirate was feculent, and decompression provided symptomatic relief. Nasogastric decompression was therefore continued for approximately 48 hours before transfer. The aspirate was recorded as feculent at insertion; its serial character and hourly volumes over the subsequent 48 hours were not documented in the referring records available to us. She had not passed stool or flatus for 2 days. Ultrasonography at that facility demonstrated multiple dilated jejunal and proximal ileal loops, collapsed distal ileal and colonic loops, and a small amount of interloop free fluid, findings consistent with small bowel obstruction. She was referred to our institution for further evaluation. Symptoms neither fully resolved nor progressed to peritonism during the interval.
Her only relevant surgical history was a tubectomy performed approximately 20 years earlier via a small suprapubic incision confined to the pelvis, the specific operative technique and extent of tubal excision were not documented in the records available to us, and this is acknowledged as a limitation. She had no other significant medical or surgical history and no prior episodes of intestinal obstruction. On specific inquiry, she was not taking any prescription medications, over-the-counter preparations, or herbal or traditional remedies, and no vaccines had been administered recently. She reported no known drug allergies.
The patient had no significant personal or family history. She gave no history of tobacco or alcohol use, and there was no family history of gastrointestinal malignancy, inflammatory bowel disease, or intestinal obstruction.
On arrival, the patient was conscious and oriented. Her vital signs were blood pressure 149/67 mmHg, pulse 65 beats per minute, peripheral oxygen saturation 96% on room air, temperature 36.8 °C, and respiratory rate 18 breaths per minute. The abdomen was soft, with mild tenderness in the left periumbilical region. There was no guarding, rigidity, or palpable mass, and bowel sounds were absent. The hernial orifices were free, and the previous suprapubic scar was intact. Nasogastric aspirate over the preceding period totaled 50 mL, and a urinary catheter, placed to monitor hydration status after several days of vomiting and reduced oral intake, had drained approximately 400 mL of straw-colored urine, indicating adequate renal perfusion at admission. Digital rectal examination showed an empty rectum.
Hemoglobin was 116 g/L, marginally below the reference range of 120-150 g/L, and the total leukocyte count was 8.96 × 109/L against a reference range of 4.0-11.0 × 109/L, with no leukocytosis to suggest established ischemia. Serum electrolytes, urea and creatinine, liver function tests, serum lactate, and C-reactive protein were all within their reference ranges, taken as sodium 135-145 mmol/L, potassium 3.5-5.0 mmol/L, urea 2.5-7.1 mmol/L, creatinine 53-97 μmol/L, alanine aminotransferase 7-35 U/L, aspartate aminotransferase 8-35 U/L, total bilirubin 3.4-20.5 μmol/L, lactate 0.5-2.2 mmol/L, and C-reactive protein less than 5 mg/L.
Chest radiography was unremarkable, with no free subdiaphragmatic gas. Preoperative echocardiography showed no contraindication to surgery (ejection fraction 60%, mild diastolic dysfunction, trivial mitral regurgitation, mild pulmonary arterial hypertension, no pericardial effusion).
Contrast-enhanced CT of the abdomen and pelvis with oral and intravenous contrast showed a normal liver with mild diffuse fatty infiltration, no biliary dilatation, and an unremarkable gallbladder, pancreas, spleen, adrenal glands, and kidneys. An abrupt transition zone was identified in a distal jejunal loop in the left paraumbilical region, with a second focal area of luminal narrowing approximately 6-8 cm proximal to it. No abnormal bowel wall thickening or mural enhancement was observed at either site. Small bowel loops proximal to the transition points were diffusely dilated, with a maximum diameter of 3.5-4.0 cm, while the distal ileum and the entire large bowel were collapsed. Oral contrast traversed only the proximal jejunal loops, with no extraluminal leak. Mild intraperitoneal free fluid was present and considered reactive; there was no pneumoperitoneum or portomesenteric venous gas. The findings were consistent with mechanical small bowel obstruction, with a well-defined distal jejunal transition point and no radiographic evidence of ischemia or perforation (Figure 1).
The preoperative study was re-reviewed retrospectively by the reporting radiologist after the operative findings became available. Specifically regarding the described signs of internal herniation, none were identified. There was no whirl sign, no beak sign at the level of the transition point, no abnormal clustering or saccular grouping of dilated loops in an atypical location, no mushroom sign, and no crowding, engorgement, or stretching of the mesenteric vessels converging on the transition point. Even with knowledge of the operative findings, no feature attributable to the transmesocolic defect could be identified in retrospect, and the appearances remained those of a mechanical small bowel obstruction with an abrupt transition point of unstated cause.
The working diagnosis was mechanical small bowel obstruction with a distal jejunal transition point of undetermined cause. In a patient with only a remote pelvic operation through a small incision, adhesive obstruction was considered unlikely. The differential for a mechanical transition point without a mass lesion included an obstructing adhesive band, an internal hernia, and, less likely, an inflammatory stricture or an early neoplasm. The absence of bowel wall thickening or abnormal enhancement on CT argued against, though did not entirely exclude, inflammatory and neoplastic causes[1,5].
Several other causes of mechanical obstruction were considered but ruled out based on the available clinical and radiological evidence. Gallstone ileus was improbable because the gallbladder was unremarkable and no ectopic calculus or pneumobilia was demonstrated. An obturator or other pelvic wall hernia was clinically excluded, with hernial orifices free on examination and no hernial sac demonstrated at any abdominal wall or pelvic aperture. Imaging did not support a paraduodenal hernia, with the transition point in a distal jejunal loop in the left paraumbilical region rather than at the duodenojejunal flexure, and no encapsulated cluster of loops was seen in a paraduodenal location. Intestinal malrotation was likewise not supported, as the duodenojejunal flexure and cecum occupied their expected positions. A congenital peritoneal band, including a Ladd’s band, could not be excluded by any preoperative test because such a band produces an abrupt transition point identical to that of a mass lesion; it remained a differential possibility until laparoscopy.
Small bowel obstruction was favored on CT findings. No CT sign specific to internal herniation including loop clustering was identified on the prospective report or the retrospective re-review described above, so this diagnosis, like the congenital band, could not be confirmed radiologically and remained provisional until laparoscopy.
The final diagnosis, established at operation, was small bowel obstruction due to a transmesocolic internal hernia, with jejunal loops herniating through a defect in the transverse mesocolon, without bowel infarction.
In view of the CT findings, the clinical picture of established mechanical obstruction, and the failure of nasogastric decompression at the referring hospital, the patient was taken to the operating room for emergency surgery on the night of admission[3,4]. She underwent diagnostic laparoscopy with reduction of the internal hernia and laparoscopic repair of the mesocolic defect under general anesthesia. Perioperative antibiotic prophylaxis comprised intravenous cefoperazone-sulbactam 1.5 g (cefoperazone 1 g with sulbactam 0.5 g) twice daily together with intravenous metronidazole 500 mg three times daily during the inpatient stay, and was stepped down at discharge to oral cefuroxime axetil 500 mg twice daily and oral metronidazole 400 mg three times daily for 5 days. Thromboprophylaxis was both mechanical and pharmacological: Intermittent pneumatic compression was applied intraoperatively and continued until she began mobilizing on the first postoperative day, and subcutaneous enoxaparin 60 mg once daily was commenced 12 hours after surgery and continued until discharge.
A 10-mm infraumbilical port was placed using the open Hasson technique, and a carbon dioxide pneumoperitoneum was established at 14 mmHg. Under laparoscopic vision, three 5-mm working ports were placed in the right lumbar, right hypochondriac, and left hypochondriac regions. Systematic exploration indicated minimal clear peritoneal fluid, dilated jejunal loops with collapsed distal ileal loops, and an internal hernia with jejunal loops passing through a defect in the transverse mesocolon, corresponding to the transition point identified on CT (Figure 2A).
The defect was ovoid, with smooth margins free of scarring or inflammatory change. Its origin could not be determined with certainty from the operative appearances alone and is not inferred here. The defect was located within the transverse mesocolon, in close relation to the middle colic vessels, which were identified and preserved throughout. Its greatest dimension was not measured during the operation, and its position relative to the middle colic vessels was not formally documented in the operative note. Neither is reported here; both are acknowledged as limitations.
The herniated jejunal loops were not incarcerated: They were contained within the defect but remained freely reducible, and were gently reduced with atraumatic graspers without division or enlargement of the defect neck. The reduced bowel was inspected along its length and was pink, peristaltic, and viable, with no residual congestion, ischemia, serosal tear, or perforation. After reduction, the mesocolic defect was clearly delineated (Figure 2B) and closed laparoscopically with interrupted 2-0 braided silk sutures, taking care to avoid the middle colic vessels within the transverse mesocolon (Figure 2C).
Braided silk was selected because it was the nonabsorbable suture immediately available in the emergency theater at the time of the operation, not on the basis of a comparative assessment of suture materials. In our hands, its handling and knot security were adequate for intracorporeal suturing of the thin, vascularized mesocolic leaf in this case; we did not compare it against alternatives intraoperatively. The field was uncontaminated: The bowel was intact and viable throughout, no enterotomy was performed, and the peritoneal fluid was clear and minimal. We note that nonabsorbable monofilament sutures, such as polypropylene, and delayed-absorbable sutures, such as polydioxanone, are commonly used in contemporary practice to close mesenteric defects and are generally preferred when the field is contaminated or the bowel is compromised, reflecting the lower propensity of monofilament material to harbor bacteria, a general principle of suture selection rather than one specific to mesocolic repair. In this patient, the postoperative course was free of surgical site infection, intraabdominal collection, or any other infectious complication. However, a single uncom
Final inspection confirmed complete reduction, a securely closed defect, and adequate hemostasis, with no additional intraabdominal pathology. An intraperitoneal drain was placed as a routine precaution given the emergency setting and recent bowel handling, rather than for a specific intraoperative indication such as contamination or uncertain hemostasis, both of which were absent; the port sites were closed. Laparoscopy is an accepted approach for selected patients with small bowel obstruction, allowing both diagnosis and definitive treatment when performed by an experienced surgeon who maintains a low threshold for conversion[4,7].
The early postoperative course was uneventful, with expected return of bowel function. On the first postoperative day, bowel sounds were sluggish, and no flatus had been passed; the patient was started on sips of clear fluids and mobilized. By the second postoperative day, bowel sounds had returned, and the volume of nasogastric aspirate had decreased, so the tube was removed. On the third postoperative day, she passed flatus and stool, tolerated a semisolid diet, and had the catheter removed. The drain was removed on the fourth postoperative day as output decreased, and a soft diet was tolerated. There were no surgical site infections, prolonged ileus requiring reintervention, or cardiorespiratory complications.
Recovery was uneventful, and the patient was discharged on the 4th postoperative day, hemodynamically stable and tolerating a soft diet. She was seen in the outpatient clinic 1 week after discharge. By then, the port-site wounds had healed, with no wound infection or port-site hernia. She reported no recurrence of abdominal pain, vomiting, or obstipation and had returned to a normal diet. At a further clinic review 2 months after surgery, she remained asymptomatic, with no recurrence of obstructive symptoms, no port-site hernia, and a normal diet tolerated. Table 1 summarizes the clinical course from symptom onset through this 2-month follow-up.
| Time point | Clinical event | Key finding or action |
| Day 1 | Onset of symptoms while travelling | Colicky periumbilical pain with progressive nausea and loss of appetite |
| Days 1-2 | Persistent symptoms | Repeated vomiting; no stool or flatus passed from day 2 |
| Day 2 | Admission to another hospital | A 16 Fr nasogastric tube placed with feculent aspirate and symptomatic relief; ultrasonography suggestive of small bowel obstruction; decompression continued for approximately 48 hours (until day 4) without resolution; referred onward |
| Day 4 | Presentation to our emergency department | Abdominal pain, vomiting and absolute constipation; hemodynamically stable |
| Day 4 | Contrast-enhanced computed tomography of the abdomen | Abrupt distal jejunal transition zone with a second focal narrowing proximally; proximal jejunum dilated to 3.5-4.0 cm; mild free fluid; no ischemia or perforation |
| Day 4 (night) | Diagnostic laparoscopy, reduction and laparoscopic mesocolic defect repair | Jejunal loops herniating through a defect in the transverse mesocolon; bowel viable after reduction; defect closed with interrupted 2-0 silk; drain placed |
| Day 5 (POD 1) | Early postoperative recovery | Bowel sounds sluggish and flatus not passed; mobilized and started on sips of clear fluid |
| Day 6 (POD 2) | Return of bowel sounds | Nasogastric aspirate fell and tube removed |
| Day 7 (POD 3) | Return of bowel function | Flatus and stool passed; semi-solid diet tolerated; urinary catheter removed |
| Day 8 (POD 4) | Drain removal and discharge | Drain removed as output declined; soft diet tolerated; discharged in a hemodynamically stable condition |
| Day 15 | Outpatient review | Reviewed one week after discharge; port site wounds healed; no recurrence of obstructive symptoms |
| 2 months | Follow-up clinic review | Reviewed 2 months after surgery; no recurrence of obstructive symptoms, no port-site hernia; tolerating a normal diet |
Internal hernias arising from congenital or acquired defects in the mesentery or mesocolon, though uncommon, should be included in the differential diagnosis of small bowel obstruction, particularly when no cause is apparent on preoperative imaging[1,3]. Adhesions account for the vast majority of mechanical obstruction, and an initial trial of nonoperative management is usually justified on that basis; that reasoning is harder to sustain when the mechanism remains unexplained, since a missed or delayed diagnosis of internal herniation carries a substantial risk of strangulation, resection, and death[1,5].
The threshold that prompted emergency surgery in this patient deserves explicit statement. Nonoperative management is a defensible default in the absence of strangulation, and the decision here was not driven by any single finding. Four considerations worked together. First, the obstruction was established rather than evolving: 4 days of colicky pain, 2 days of absolute constipation, and a feculent nasogastric aspirate indicated a distal small bowel obstruction of some standing rather than a transient ileus. Second, and most importantly, an adequate trial of nonoperative management had already been conducted and had failed. The patient had undergone approximately 48 hours of nasogastric decompression at the referring hospital, with symptomatic relief but no resolution. She had still passed neither stool nor flatus, and the obstruction persisted radiologically upon arrival. Continued observation would therefore have been a repetition of a strategy already shown not to work, rather than a first attempt at it. Third, CT demonstrated a fixed, abrupt transition point with a second focal narrowing proximal to it, indicating a mechanical lesion at a fixed anatomical site rather than a functional or adhesive process likely to resolve. Fourth, the mechanism of the obstruction itself remained unidentified, so the usual justification for prolonged conservative management a high prior probability of adhesive obstruction that will resolve could not be assumed[3,4]. Conversely, the absence of strangulation on clinical, biochemical, and radiological grounds was precisely what permitted the operation to be performed as a planned emergency procedure on the night of admission, with viable bowel and a realistic prospect of avoiding resection, rather than as a salvage laparotomy. Timing, in this sense, was determined by decompression failure and the fixed transition point; the absence of ischemia indicated only that there was time to proceed in an orderly manner.
Cross-sectional imaging with contrast-enhanced CT is central to preoperative evaluation. It reliably confirms mechan
In the present case, the preoperative report described a mechanical obstruction with an abrupt distal jejunal transition point and made no mention of the specific signs of internal herniation, so the cause was not identified before operation. The retrospective re-review described above explains why none of the signs were present. That a reader who already knew the operative diagnosis could still identify no whirl sign, beak, abnormal clustering, or mesenteric vascular abnormality suggests that these features were genuinely absent rather than merely overlooked. In this patient, the retrospective re-review suggests that vigilance alone might not have yielded the diagnosis from the images available, although a single retrospective read by one radiologist cannot establish this with certainty. This experience illustrates a limitation worth stating explicitly for the readers. The radiologist is rarely primed to look for an internal hernia, and the signs that would suggest one are neither sensitive nor conspicuous unless specifically sought. Two practical measures follow. The requesting surgeon should explicitly ask on the imaging request whether an internal hernia is present, since these signs are reported to be more readily identified when specifically sought[1,5]. When the mechanism remains unexplained after CT, the absence of a named cause should not be taken as reassurance, since internal herniation is among the causes of mechanical obstruction least likely to be identified on preoperative imaging[2,5,6].
In this patient, CT identified an abrupt jejunal transition point without signs of wall compromise, which correlated closely with the intraoperative finding of an internal hernia through a defect in the transverse mesocolon. The value of the scan lay less in identifying the cause than in establishing that the obstruction was mechanical, localizing it, and excluding ischemia and perforation, which together shaped the decision to operate promptly.
The differential diagnosis for an unexplained mechanical transition point is broader than that for an internal hernia alone, and the rationale for excluding the alternatives is provided in the Final Diagnosis section above. In brief, gallstone ileus, obturator hernia, paraduodenal hernia, and malrotation were each excluded on clinical or radiologic grounds, while a congenital peritoneal band, such as a Ladd’s band, remained a genuine possibility until laparoscopy and was excluded only at operation. That a band cannot be distinguished from an internal hernia on any preoperative test is itself an argument for early exploration, since both diagnoses require operative treatment and neither resolves with decom
Early surgical intervention combined with a laparoscopic approach allowed prompt reduction of the herniated bowel, confirmation of viability and definitive repair of the underlying defect, minimizing the risk of ischemia, resection and associated morbidity[4,7]. Laparoscopy is an established option for selected patients with small bowel obstruction; in general SBO cohorts, dominated by adhesive disease, it has been associated with shorter recovery, earlier return of bowel function, and fewer wound complications, provided the surgeon maintains a low threshold for conversion when exposure is inadequate, when the bowel is distended to the point of injury risk, or when viability is uncertain[4,7]. Evidence specific to laparoscopic management of internal hernia is limited to case reports and small series, so these comparative advantages should be extrapolated to this diagnosis with caution rather than assumed. The approach was selected here for reasons specific to this patient rather than as a general preference. The proximal small bowel was dilated to no more than 4.0 cm; in our intraoperative judgment this was a caliber that could be handled atraumatically with graspers, though we are not aware of a validated diameter threshold for laparoscopic safety, and this reflects operative judgment rather than an established cutoff. There was no clinical, biochemical or radiological evidence of strangulation, so neither resection nor rapid vascular control was likely to be required. The transition point had been localized preoperatively to a distal jejunal loop, allowing a targeted rather than exhaustive exploration. Had any of these conditions not been met, particularly the caliber of the bowel or the absence of ischemia, conversion would have been the correct decision, and the threshold for it was set before the operation began. Two technical points deserve emphasis. First, viability must be confirmed along the entire reduced segment, since a congested bowel may appear unhealthy immediately after reduction and then recover, while an apparently viable bowel may harbor a segmental injury at the neck of the defect. In the present case, no such concern arose, as the loops were freely reducible and showed no venous congestion at any point. Second, the defect itself must be closed securely, because leaving it open invites recurrent herniation; interrupted non-absorbable sutures placed with care to avoid the middle colic vessels achieve this without compromising colonic perfusion.
Transmesocolic hernias, in which the bowel passes through a defect in the mesocolon rather than in the small-bowel mesentery, are among the rarest types of internal hernias. In adults, they are more often attributed to prior surgery, trauma, or inflammation than to a congenital defect[1,5]. Reports of congenital defects in adults are consequently scarce. Adult cases arising from congenital mesenteric and mesocolic defects have been described in the third to ninth decades of life and have consistently presented with nonspecific obstructive symptoms, with the cause most often recognized only at operation[8-12]. Of these, the report closest to the present case in site and presentation is that of an elderly woman with a strangulated transmesocolic hernia[11], while a defect in the mesentery of the transverse colon has also been described in a young man[10]. More recent reports document the same pattern and illustrate how closely outcomes track the timing of intervention: When the bowel was still viable, it could be reduced and the defect closed primarily, whereas delayed presentation led to segmental resection or stoma formation once ischemia had supervened[13,14]. A recent report similarly describes internal herniation causing obstruction in an elderly patient in whom radiography and ultrasonography were nondiagnostic[15]. The comparative literature discussed below was identified by searching PubMed/MEDLINE, Scopus, and Google Scholar from inception to July 2026 using the terms “internal hernia”, “transmesenteric hernia”, “transmesocolic hernia”, “mesenteric defect”, “small bowel obstruction”, and “laparoscopy”, alone and in combination; reference lists of retrieved articles were hand-searched, and English-language reports of adult cases were retained. A selection of published adult cases of transmesenteric or transmesocolic hernia is summarized in Table 2 (reviews and multi-patient series without individual case detail, and pediatric reports, are discussed narratively below rather than tabulated), from which two observations can be drawn. First, the presentation is uniformly nonspecific. Preoperative imaging established the diagnosis in 7 of the 14 tabulated cases and raised it in a further 3, while in the remaining 4 the internal hernia was recognized only at operation. Second, 9 of the 14 underwent bowel resection. Individual reports describing a delayed presentation attribute this to ischemia already established at operation[13,14], but the interval to operation is not reported consistently enough across these cases to be tabulated, so no relationship between that interval and bowel loss can be drawn from these data. The present case differs from most of these in that the herniated loops were never incarcerated: Despite 4 days of obstruction, the bowel remained freely reducible and uncongested, making a wholly laparoscopic reduction and primary closure of the mesocolic defect feasible[10,13] without resorting to resection.
| Ref. | Age, sex | Hernia type/site | Diagnosis | Management | Resection | Outcome |
| Gyedu et al[8], 2010 | 22, Male | Transmesenteric (jejunal/ileal) | Diagnosed intraoperatively; not established preoperatively | Open laparotomy | Yes | Recovery reported; not detailed further |
| Butterworth et al[9], 2013 | 26, Female | Transmesenteric, jejunum and proximal ileum | Not by preoperative CT; diagnosed at exploratory laparoscopy | Laparoscopy converted to open | Yes | Good recovery; discharged day 5 |
| Edwards et al[10], 2013 | 32, Male | Transmesenteric, transverse colon mesentery | Preoperative CT | Open emergency laparotomy | No | Discharged day 4; no recurrence at 18 months |
| Jung et al[11], 2013 | 84, Female | Transmesocolic, beneath transverse colon | Preoperative CT | Emergency surgery (approach not reported) | Yes | Discharged POD11; favorable |
| Crispín-Trebejo et al[12], 2014 | 63, Female | Transmesenteric (transverse colon via meso-sigmoid defect, with volvulus) | Preoperative imaging; confirmed at laparoscopy | Laparoscopic derotation and cecopexy | No | Favorable; not further detailed |
| Beji et al[13], 2022 | 35, Male | Transmesenteric, distal ileum (congenital 2 cm defect) | Preoperative CT | Open laparotomy | Yes | Recovered uneventfully |
| Songadkar et al[14], 2024 | 22, Male | Transmesenteric, distal ileum | Preoperative CT suggestive; confirmed at laparotomy | Open emergency laparotomy + end-ileostomy (later reversed) | Yes | Uneventful after ileostomy reversal |
| Sinha et al[15], 2025 | 81, Male | Transmesenteric, ileal (mesenteric band) | Preoperative CT | Surgical exploration; band divided | No | Discharged home; postoperative pneumonia, recovered |
| Katagiri et al[20], 2013 | 18, Female | Transmesenteric, jejunal (3 cm defect) | Preoperative CT suggestive; definitive diagnosis intraoperative | Open emergency laparotomy | Yes | Discharged POD6; uneventful |
| González-Luna et al[21], 2024 | 35, Female | Transmesenteric, terminal ileum | Diagnostic laparoscopy (preoperative imaging not reported) | Laparoscopy converted to open | Yes | Discharged 72 hours; good at follow-up |
| Aparício et al[23], 2019 (Case 1) | 40, Male | Transmesocolic (descending), sigmoid colon | Preoperative CT and colonoscopy | Open laparotomy (Hartmann) | Yes | Discharged POD6; asymptomatic at 2 years |
| Aparício et al[23], 2019 (Case 2) | 92, Female | Transmesocolic (transverse) and transomental, sigmoid colon | Preoperative CT | Open laparotomy (Hartmann) | Yes | Discharged POD5; asymptomatic at 3 months |
| Kishiki et al[24], 2015 | 61, Male | Transmesocolic, transverse colon | Preoperative imaging | Laparoscopic repair | No | Discharged POD6; no recurrence at 1 year |
| Zhang et al[25], 2023 | 45, Female | Transmesocolic, transverse mesocolon | Diagnosed intraoperatively at laparoscopy | Emergency laparoscopic exploration | No | Discharged POD6; favorable at 6 months |
| Present case | 62, Female | Transmesocolic, transverse mesocolon | Preoperative CT showed transition point only; hernia diagnosed intraoperatively | Diagnostic laparoscopy; primary closure | No | Discharged POD4; asymptomatic at 2 months |
The wider literature underscores how challenging this diagnosis is. In an early series correlating CT with operative findings, the characteristic signs were present in only a proportion of surgically confirmed internal hernias[16]. The features described in the postoperative setting, where internal hernias are most common, include abnormal clustering of loops, mesenteric vascular crowding, and displacement of adjacent viscera[17]. A review of 49 nonbariatric internal hernias likewise found that presentations were often nonspecific, with outcomes depending on the timing of surgery[18]. Herniation through congenital mesenteric or mesocolic defects in adults remains individually rare but collectively instructive. A congenital sigmoid-level defect was identified during diagnostic laparoscopy after nonoperative man
One small case series estimates that transmesocolic defects account for approximately 8% of internal hernias, though this figure derives from limited published data rather than a large epidemiologic sample; reported cases most often require resection once the herniated viscus has strangulated[23]. The most directly comparable published case is that of a man in his seventh decade, in whom small bowel herniated through a defect in the transverse mesocolon without strangulation, and the hernia was diagnosed on CT and repaired laparoscopically[24]. This journal has published a closely related case in which a 45-year-old woman underwent emergency laparoscopy for obstruction caused by a transverse mesocolic defect that was deemed too large to close and was therefore left open[25]. Read alongside these, the contribution of the present case lies less in the anatomy, which has now been documented several times, than in the management: An obstruction of 4 days’ standing in which the herniated loops were nonetheless still freely reducible and viable, allowing reduction and primary closure via a purely laparoscopic approach.
Three limitations should be acknowledged. First, the specific CT signs of internal herniation were not prospectively sought. The retrospective re-review was necessarily performed with knowledge of the operative findings, a circumstance that ordinarily biases toward identifying features not appreciated at the time, yet no such features were identified. Second, the greatest dimension of the mesocolic defect was not measured during the operation, and its position relative to the middle colic vessels was not formally recorded. As a result, the defect cannot be quantitatively related to either the risk of recurrence or the choice between primary closure and leaving the defect open, a comparison of direct relevance here, given that a previously reported transverse mesocolic defect was judged too large to close and was left open[25]. Third, the choice of braided silk for closure reflected immediate availability rather than a comparative assessment of suture materials, so no conclusion about the optimal material can be drawn from this case. As presented in Table 2, the published experience consists entirely of isolated case reports, and the true incidence and optimal management of these hernias remain undefined. No probability scale or validated causality instrument is applicable to a mechanical surgical diagnosis of this type. The findings should therefore be read as hypothesis-generating and as a reminder of a diagnosis that is easy to miss, rather than as evidence favoring one operative strategy over another.
Internal herniation through a defect in the mesentery or mesocolon is an uncommon but important cause of small bowel obstruction. It warrants early consideration when a mechanical obstruction persists despite decompression or remains otherwise unexplained, since nonoperative management may be unsafe once these features are present. Contrast-enhanced CT should be obtained promptly to confirm the obstruction, localize the transition point, and exclude ischemia or perforation, recognizing that the specific mechanism is often established only at operation. When expertise is available, diagnostic laparoscopy can provide both diagnosis and definitive treatment in selected patients, with a low threshold for conversion maintained whenever exposure is inadequate or bowel viability is in doubt. Larger multicenter registries would help define the incidence and optimal management of internal hernia in adults.
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