Rare Presentation of Spontaneous Transomental Hernia in an Elderly Oncology Patient: Diagnostic Vigilance and Surgical Management

Abstract

Background: Transomental hernia (TOH) is a rare internal hernia, representing approximately 1-4% of all internal hernia cases. The spontaneous form, occurring in patients without a history of abdominal surgery or trauma, is exceptionally uncommon and presents a significant diagnostic challenge due to its nonspecific clinical features. TOH typically involves herniation of small bowel loops through a defect in the greater omentum.

Case presentation: We report a case of spontaneous TOH in a 76-year-old male undergoing chemotherapy for synchronous primary malignancies - left lung adenocarcinoma and right renal cell carcinoma - who presented with features of intestinal obstruction. Contrast-enhanced computed tomography suggested internal herniation with ischemia. Intraoperative findings confirmed approximately 100 cm of small bowel incarcerated through a 3-cm defect in the right side of the greater omentum. Age-related omental atrophy, along with chemotherapy-induced mesenteric fibrosis, microvascular injury, and impaired regenerative capacity, likely contributed to the defect formation. An emergency midline laparotomy was performed, involving resection of the gangrenous bowel and the creation of a double-barrel enterostomy. Postoperatively, distal enteral refeeding was critical in electrolyte correction, nutritional support, and early recovery.

Discussion: TOH carries a high risk of strangulation and should be considered in elderly patients with bowel obstruction, even with no history of prior abdominal surgery, especially those receiving platinum-based chemotherapy.

Conclusion: Although rare, TOH should be included in the differential diagnosis of acute abdomen in elderly oncology patients, even without previous abdominal surgery. Timely surgical intervention is vital to reduce morbidity and optimize outcomes.

Keywords: Chemotherapy; Distal loop refeeding; Internal hernia; Spontaneous bowel obstruction; Transomental hernia.

Fig. 1.

Coronal CECT image of the abdomen demonstrating features of a spontaneous TOH. The yellow arrow indicates the hernia neck, through which the small bowel loop has herniated – the blue arrow points to gas within the mural layer of the bowel, suggesting bowel wall gangrene.

Fig. 2.

Intraoperative image showing an incarcerated gangrenous small bowel loop herniating through a defect in the greater omentum, consistent with a spontaneous TOH. The dusky appearance of the bowel is indicative of compromised vascularity and gangrene.

Fig. 3.

Intraoperative view following hernia reduction, showing the transition point at the hernia neck with adjacent congested and dusky small bowel loops. The clear demarcation between viable and compromised bowel segments indicates vascular compromise at the site of incarceration.

Fig. 4.

Resected specimen of the gangrenous small bowel, approximately 100 cm in length, showing extensive hemorrhagic congestion and transmural necrosis secondary to a strangulated TOH.

Fig. 5.

Postoperative image showing double-barrel jejunoileostomy fashioned in the right stoma triangle, with a well-approximated midline laparotomy incision closed with skin staples.

Fig. 6.

Distal loop enteral refeeding performed via a Foley catheter inserted into the distal limb of the double-barrel jejunoileostomy. Collected proximal effluent is shown to be reinfused to maintain intestinal continuity and nutrient absorption.