Intramesenteric internal hernia with midgut volvulus: a rare case causing small bowel gangrene in an adult

Intramesenteric internal hernia is a rare type of small bowel mesentery related internal hernia which usually occur in pediatric population. It is characterized by herniation of small bowel loops through a congenital or acquired defect in one layer of the mesentery producing a mesenteric pouch type hernia. The defect usually occurs near the ileocaecal valve or ligament of treitz and the herniated bowel loops are prone to strangulation or volvulus, presenting as small bowel obstruction that warrants early recognition and emergency laparotomy to confirm the diagnosis and prevent bowel gangrene and its complication. We present a case of 59 year old male presenting with features of an acute intestinal obstruction since morning and a vague firm mass in the right upper quadrant which was confirmed by CT scan to be an internal hernia and patient was taken up for emergency laparotomy. Intraoperative findings revealed a sac of small bowel loops herniating into the mesentery through a defect near the terminal ileum. Upon reducing the contents a volvulus was evident and resulted in the gangrene of the small bowel loops. The gangrenous bowel was resected and a single layered end to end ileo-ileal anastamosis was done. The diagnosis of internal hernia in a adult with no previous history of abdominal surgery or trauma is a very rare entity and requires a high degree of suspicion and close monitoring of the patient to ensure early surgical intervention and optimal outcome.