Surgical Science, 2011, 2, 341-343
doi:10.4236/ss.2011.26073 Published Online August 2011 (
Copyright © 2011 SciRes. SS
An Unusual Case of Right Transmesocolic Hernia with
Ureter at the Neck of Sac
Mahendra Singh Gond, Arjun Saxena, Pawan Agarwal, Uday Somashekar, Dhananjaya Sharma*
Department of Surgery, Gove rnment NSCB Medical C ol le ge , Jabalpur, India
Received March 5, 2011; revised May 17, 2011; accepted June 20, 2011
The purpose of the present article is to present an unusual case of internal herniation. In this case small bowl
obstruction was due to congenital right trans-mesocolic hernia which had the right ureter at the neck of the
sac forming a constriction band. This requires careful widening of neck of hernia, so as to avoid iatrogenic
trauma to ureter. This unusual presentation needs dissemination as this type of internal hernia is extremely
Keywords: Hernia, Abdominal/Surgery, Intestinal Obstruction/Etiology/Surgery, Mesocolon/Pathology/
1. Introduction
Internal hernia is a rare cause of intestinal obstruction
with a reported incidence of less than 1% [1-3]. Its pres-
entation is usually non-specific. Key to its successful
operative management is to safeguard the important vas-
cular structures like superior mesenteric artery and infe-
rior mesent eric vein, etc whic h course t hrough the neck of
these hernias [4]. In this case report we present an unusual
case of a congenital right transmesocolic hernia with
small bowel obstruction which had right ureter at the
neck of the sac forming a constriction band. Right
ureter has not been reported near the neck of any internal
herniation; which makes dissemination of this unusual
and rare presentation important, so inadve rtent iatrogenic
trauma can be avoided to this important structure.
2. Case Report
A 35 year old male was admitted in the surgical ward
with acute abdominal pain and vomiting. He had a his-
tory of similar self limiting episodes in the last 5 years.
There was no history of previous abdominal surgery.
Abdominal examination revealed generalised abdominal
distension, with sluggish bowel sounds; guarding and
rigidity were absent. General parameters and routine
blood investigations were normal. Plain abdominal x-ray
showed multiple air fluid levels (Figure 1). Ultrasono-
graphy showed dilated bowel loops, with to and fro mo-
tion. The patient did not improve with 48 hours of con-
servative treatment and was then taken up for explora-
tory laparotomy.
Mid line vertical laparotomy was done. A defect of 5
cm diameter was found in the mesentery of ascending
colon. The entire small gut except th e proximal 15 cm of
jejunum and terminal ileum had herniated through the
Figure 1. Scout film abdomen in upright position showing
multiple fluid levels.
defect and was contained behind the ascending colon
creating a retroperitoneal bulge. The caecum and as-
cending colon were mobilised after incising the perito-
neal fold along the ascend ing colon. The herniated small
bowel was viable but congested. A tubular structure was
found in the neck of hernia sac, which on closer inspec-
tion was determined to be the right ureter (Figures 2 and
3). In order to avoid injury to ureter and to widen the
neck and to relieve the obstruction, mesocolic defect was
widened in the caudal direction, avoiding superior mes-
enteric vessels on the medial side. There after the herni-
ated loops were pulled back into the peritoneal cavity
and the defect was closed by suturing the margins of the
defect to the retro peritoneum. The postoperative recov-
ery was uneventful.
3. Discussion
Internal hernias are defined as protrusion of a viscus
Ri g h t
De fe c t
Figure 2. Operative photograph showing right ureter the
neck of hernia sac.
Figure 3. Diagrammatic representation of operative finding
showing right ureter the neck of hernia sac.
through a normal or abnormal peritoneal or mesenteric
aperture within the confines of the peritoneal cavity. The
orifice can be either acquired, such as a postsurgical,
traumatic, or postinflammatory defect, or congenital,
including both normal apertures, such as the foramen of
Winslow, and abnormal apertures arising from anomalies
of internal rotation and peritoneal attachment [1]. With
more new surgical procedures being performed using a
Roux loop, the number of transmesenteric, transmeso-
colic, and retroanastomotic internal hernias are increas-
ing [5].
Preoperative clinical diagnosis of internal hernia is ex-
tremely difficult because of the nonspecific clinical
presentation [6]. Ultrasonography and Computed Tomo-
graphy are helpful with observation of a saclike mass or
cluster of dilated small bowel loops at an abnormal
anatomic location [7,8].
Internal herniation through right mesocolon is ex-
tremely rare, with very few ca ses having been rep orted [9,
10]. Surgeons are taught to keep important vascular
structures in mind when incising the neck of internal
hernia; e.g. inferior mesenteric vein and ascending left
colic artery (left paraduodenal hernia), superior mesen-
teric artery (right paraduodenal hernia) and portal traid
(foramen of Winslow hernia). In the present unusual case
small bowel loops migrated through a congenital defect
in the mesentry of ascending co lon to come to lie behind
the ascending colon. There was no malrotation as evident
by normal location of the duodeno-jejunal and ileocecal
junctions. The right ureter located in the anterior edge of
such a mesocolic defect is susceptible to injury if it is not
identified and protected while incising the edges to re-
lease the entrapped bowel.
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