Congenital intramesenteric hernia presenting as small bowel obstruction in children: A case series

Intramesenteric hernia is an exceedingly rare congenital internal hernia characterized by herniation of bowel loops between the two layers of the mesentery, forming a true sac. Case 1: A 1-year-and-6-month-old boy presented with bilious vomiting and abdominal distension for two days. He appeared ill and dehydrated, was afebrile and tachycardic, with normal blood pressure. The abdomen was distended without tenderness or guarding. Plain radiograph and ultrasound demonstrated features of small bowel obstruction. After initial resuscitation with intravenous fluids and antibiotics, surgery was undertaken due to radiological evidence of obstruction. Exploratory laparotomy revealed a sac within the distal ileal mesentery containing viable small bowel loops, which was plicated using absorbable sutures. His postoperative recovery was uneventful. Oral feedings were started on postoperative day 2, and he was discharged on postoperative day 5. Case 2: A 2-year-old girl presented with similar features. She was afebrile and in pain, hemodynamically stable, with a distended, tender abdomen. Ultrasonography demonstrated dilated small bowel loops. Supine abdominal X-ray showed multiple dilated small bowel loops with absent rectal gas. Laparoscopic exploration revealed an intramesenteric pouch containing viable bowel near the distal ileum, which was reduced and plicated through a limited incision. She had an uncomplicated postoperative course. Oral feedings were started on postoperative day 2, and she was discharged on postoperative day 6. At the 3-month follow-up, both children were asymptomatic. Intramesenteric hernia should be considered in the differential diagnosis of pediatric small bowel obstruction.