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Introduction and Importance: Spontaneous trans-mesenteric hernia is a rare entity in adults. Its pre-operative diagnosis is challenging even with Computed Tomography Scanning. Most cases are diagnosed as incidental findings during laparotomy or postmortem. This case report highlights that even in geriatric patients without prior laparotomies, peritonitis or abdominal trauma which predispose to trans-mesenteric herniation, a differential diagnosis of a spontaneous trans-mesenteric hernia is of paramount importance as delay in diagnosis leads to death., Case Presentation: We report a case of a geriatric lady who presented with features of intestinal obstruction. Intra-operative findings revealed strangulated gangrenous small bowels extending from 170 cm from ligament of Treitz to the ileal caecal junction through a trans-mesenteric defect of about 12 cm in diameter. She underwent resection of the gangrenous small bowel with right hemi colectomy and jejunal-transverse colon end to side anastomosis. However, she succumbed two days post operatively., Clinical Discussion: Spontaneous trans-mesenteric hernia is a rare cause of small bowel obstruction in adults, difficult to clinically and radiologically diagnose pre-operatively and mostly presents with bowel ischaemia due to strangulation. Early diagnosis is paramount in reducing morbidity and mortality rates in these cases., Conclusion: Delay in diagnosis of trans-mesenteric hernia leads to strangulation, gangrene of bowels and eventual death. A high index of suspicion is needed from both surgeons and radiologists even in cases of intestinal obstruction without prior histories of laparotomy, peritonitis or abdominal trauma., Competing Interests: Declaration of competing interest The authors declare they have no competing interests. All authors of the manuscript have read and agreed to its contents., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)