Transmesosigmoid hernia with small bowel strangulation

Introduction: Internal herniation of the small bowel is difficult to diagnose before surgery. Delayed laparotomy is related to high morbidity and mortality. We present a rare case of a transmesosigmoid hernia to demonstrate the importance of high suspicion and early laparotomy. Case Report: A 44­year­old female patient had severe abdominal pain of acute onset. A CT scan at six hours after onset of the symptom showed a dilated small bowel loop of diminished attenuation. Her severe pain was not controlled even with narcotics. An emergency laparotomy eight hours after onset revealed about a 150 cm strangulated closed loop of the mid small intestine, herniated through a small mesenteric defect of the sigmoid colon. The defect in the mesosigmoid was about three cm in diameter without a sac, and functioned similarly to a napkin ring; therefore the reduction of the herniated closed intestine loop was difficult without division of the intestine. The patient recovered well after resection anastomosis and closure of the mesenteric defect. Conclusion: Congenital internal hernia is rare, but early development of incarceration and strangulation is associated with increased morbidity and mortality. Early suspicion and urgent or emergent laparotomy or laparoscopic exploration and surgical management are necessary.