A transomental hernia is a rare cause of Not only in virgin cases small bowel obstruction that is occasionally diagnosed during surgery [1,2,3,4,5,6]. Preoperative diagnosis of transomental hernia is difficult, but abdominal CT can help to detect strangulation ileus resulting from transomental hernia as in these two cases [1,2,3,4]. A transomental hernia shows finding of small bowel obstruction. In our two cases, transverse colon loops were located posterior to dilated intestinal loops, as previously reported . Identification of intestinal localization was easier by using the CE-CT. That was why we used the CE-CT as the initial imaging study for case 2. This finding might be specific and useful for the diagnosis of transomental hernia. Because the necessity for emergency surgery was not clearly informed in the first plain CT in case 1, the patient was initially treated conservatively. Emergency surgery is usually recommended for cases of small bowel obstruction in patients with a virgin abdomen . Earlier laparoscopic surgery following the earlier diagnosis might have avoided the conversion to laparotomy in the first case.
The best approach for the surgery of small bowel obstruction with strangulation is controversial. In case 1, the color of the intestinal tract under the observation by laparoscopy led to a concern of its viability. That was why the procedure was switched to a laparotomy. The viability of a strangulated intestine can be judged by the color and the presence of swelling resulting from ischemia and compression of the intestinal wall. Palpation with gazing for pulsation of the small mesenteric arteries and tactile evaluation of the wall thickness are possible only under the laparotomy. Visible light spectrophotometry and laser Doppler flowmetry can help to determine whether bowel preservation is possible without a need of laparotomy . The use of indocyanine green to evaluate intestinal blood flow during surgery for incarcerated hernia has also been reported . If such method for evaluating intestinal blood flow had been available, the laparotomy might be unnecessary in case 1. In case 2, laparotomy was not needed to confirm the viability of the involved portion of intestine, because the involved length was shorter and the discoloration of the intestine was milder than the case 1.
The laparoscopic approach to small bowel obstruction has been expanded these days . Based on our experience, laparoscopic surgery should be applied even in cases with strangulation unless there are clear preoperative signs of perforation or necrosis. We can expect the completion of the procedure without conversion to laparotomy like in case 2. Usage of sophisticated instruments for detection of blood supply to the intestine might increase the possibility of complete laparoscopic surgery in those cases. Not only in virgin cases but also in cases with positive history of surgery or trauma, laparoscopic approach can be applied unless the patient has definite contraindications . Of course, in that situation, we should not hesitate to convert to laparotomy if there is a concern about the complications.