Closed loop small bowel obstruction - omental adhesion causing "internal hernia"

Case contributed by Michael P Hartung


Abdominal pain.

Patient Data

Age: 55 years
Gender: Male

Clustered of mildly thickened small bowel in the left abdomen with mesenteric edema and vessels radiating toward a narrowed transition point where the small bowel enters/exits this cluster. Swirling and abnormal angulation of upper abdominal vasculature. Cranial displacement of the splenic flexure. 

Case Discussion

This case illustrates a common trend I have observed when reading operative notes - often surgeons find the equivalent of an internal hernia caused by an adhesive band, and that find that description to be the most accurate of what they observed (even through internal hernias are technically reserved for congenital peritoneal fossae or surgical defects, not adhesions). There are classic findings of closed-loop physiology with a cluster of small bowel with mesenteric edema and mass effect in the left abdomen radiating toward a narrow transition point where the bowel enters and exits the cluster. 

Operative note excerpt (edited): "We could immediately see ischemic small bowel in the left upper quadrant, congested and with chylous ascites. It appeared to go through an internal hernia. In order to reduce the bowel, we had to divide the omental adhesion causing the internal hernia. The bowel pinked up after we reduced the internal hernia, and we did not resect any bowel. We lysed one additional omental band that could be a future site of torsion..."

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