Liu et al.

BMC Surgery (2020) 20:14

https://doi.org/10.1186/s12893-019-0665-7

CASE REPORT Open Access

An extremely rare case of lesser omental

hernia in an elderly female patient
following total colectomy
Zhicheng Liu1, Liang He1, Yan Jiao2, Zhonghang Xu3 and Jian Suo1*

Abstract
Background: An intro-abdominal hernia through the lesser omentum is a rare but severe condition that can cause
intestinal obstruction and other life-threating complications. Until now, only a handful of cases have been reported
worldwide. The diagnosis of lesser omental hernia remains challenging for emergency surgeons because of the
unspecific symptoms. Therefore, there is a need for a better understanding of the characteristics of this condition.
Case presentation: In this report, we described the case of a 73-year-old female patient who was diagnosed with
a lesser omental hernia caused by previous total colectomy. The patient underwent emergency surgery, and the
intraoperative findings revealed a 200-cm segment of the small intestine was herniated through a defected lesser
omentum (approximately 3 × 4 cm) from the lesser retrogastric curvature of the stomach. Besides, we summarize
the specific abdominal computed tomography (CT) findings of lesser omental hernia by reviewing the literature.
Conclusion: The lesser omental hernia is extremely rare but can cause serious complications. The cause of lesser
omental hernia can be congenital or acquired. Careful examination of the small omentum before the closure of the
abdomen is expected to reduce the occurrence of these abdominal surgery-associated complications. The specific
features of abdominal CT in cases of lesser omental hernia, which are summarized in this article, can help other
clinicians to obtain accurate diagnoses of lesser omentum hernia in the future.
Keywords: Internal hernia, Lesser omental hernia, Intestinal obstruction, Total colectomy

Background was performed 2 years earlier. We also conduct a litera-

The lesser omental hernia is a rare form of intestinal hernia. ture review on the lesser omental hernia.
However, it is a severe clinical condition and can result in
intestinal obstruction and other life-threatening complica- Case presentation
tions [1, 2]. To date, very few cases of lesser omental hernia Patient description
have been reported across the world [3–13]. It is challen- An elderly female patient, aged 73-year-old, was admitted
ging for emergency surgeons to make a timely and accurate to our hospital for unexplained acute abdominal pain and
diagnosis of lesser omental hernia, as the symptoms are bloating after the occurrence of vomiting. Upon admis-
unspecific and overlap with those of other gastrointestinal sion, the patient was observed to have an abdominal bulge
diseases. Therefore, a better understanding of the charac- and total abdominal tenderness accompanied by rebound
teristics of lesser omental hernia is needed. pain and muscle tension. The patient had a medical his-
In this study, we describe an uncommon case of lesser tory of total colectomy in combination with an ileal
omental hernia in a 73-year-old female patient that ap- pouch-anal anastomosis (IPAA) for the treatment of func-
peared to be mainly caused by a total colectomy that tional chronic constipation or chronic idiopathic constipa-
tion (CIC) 2 years before hospital admission.

* Correspondence: [email protected] Examinations and diagnosis

1
Department of Gastrointestinal Surgery, The First Hospital of Jilin University,
71 Xinmin Ave., Changchun 130021, Jilin, China General physical examinations were as follows: heart
Full list of author information is available at the end of the article rate: 120 bpm; blood pressure: 85/50 mmHg; Laboratory
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Liu et al. BMC Surgery (2020) 20:14 Page 2 of 5

tests revealed a white blood cell (WBC) count of 17 × hernias [1]. This type of hernia is characterized by the
109 / L, and lactic acid (LA) level of 6.3 mmol / L; Ab- protrusion of organs in the abdomen through normal or
dominal enhanced computed tomography (CT) showed abnormal openings (pouches) into the abdominal cavity.
dilation, as well as gas and liquid accumulation in the Intra-abdominal hernias are categorized according to the
distal portion of the small intestine, ventral to the dis- cause as either congenital intra-abdominal hernia (e.g.,
torted stomach. It was observed that a segment of the duodenal fistula, Winslow hernia) or acquired intra-
small intestine was prolapsed via the defected lesser abdominal hernia, caused by surgery, trauma, inflamma-
omentum, passing the retrogastric lesser curvature to tion, and other factors that can result in defects in the
enter the ventral part of the stomach. CT images in the greater omentum or lesser omentum. Compared with
abdomen also revealed a hypodensity in some fragments greater omentum hernia, lesser omentum hernia is con-
of the small intestine, liquid accumulation around the siderably rarer, with only a few reported cases. Kita-
liver and spleen, as well as pelvic effusion (Fig. 1). gishiet and colleagues classified lesser omental hernias
Based upon the abdominal CT findings, the patient into two types: type I and type II. In type I lesser omen-
was diagnosed with having a lesser omental hernia com- tum hernia, the intestine prolapses directly into the
plicated with intestinal obstruction, acute diffuse peri- lesser omental sac through the lesser omentum, whereas,
tonitis, and septic shock. in type II, lesser omentum hernia, the gastrocolic liga-
ment and the small intestine prolapses from the retro-
Treatment gastric curvature into the abdominal cavity through the
The patient was immediately treated with an emergency lesser omentum. The present case was classified as type
laparotomy. During the procedure, ascites, of approxi- II lesser omental hernia, based on the main intraopera-
mately 1500 ml liquid with blood, were observed. Notably, tive finding that the small intestine prolapsed from the
a fragment of the small intestine protruded from the lesser lesser retrogastric space of the stomach through a
retrogastric curvature of the stomach into a defected lesser defected lesser omentum into the abdominal cavity. Fur-
omentum (Fig. 2a) and appeared necrotic and black. The thermore, the patient had a medical history of total col-
defected omentum was approximately 3 × 4 cm in size ectomy but had no evidence of inflammation or
(Fig. 2b), with the necrotic fragment of the small intestine adhesion around the defected lesser omentum. She did
measuring approximately 200-cm in length. The necrotic not have a history of trauma or congenital abnormality.
portion of the small intestine was resected, anastomosis The defect in the lesser omentum in our patient was
was performed, and the defected lesser omentum was likely caused by the previous total colectomy.
closed. The patient was subsequently transferred to the in- Additionally, we performed a literature search using
tensive care unit (ICU). The tracheal intubation was re- the keyword “lesser omental hernia” and obtained a total
moved 2 days after the operation, and the patient was of 11 reports in PubMed. The findings of these cases, in-
transferred to a local hospital for further treatment. cluding ours, are summarized in Table 1 [3–13]. The
The risks and benefits of the surgical procedures were mean age of the patients was 43.5 years, ranging from 14
explained to the patient, and written informed consent to 73 years. The 11 previously reported cases and our
was obtained. case of lesser omental hernia consisted of six males and
six females. Type I patterns were observed in five pa-
Discussion and conclusion tients, while type II patterns were found in seven pa-
Intra-abdominal hernias represent a rare type of internal tients. The patient in the present study was defined as
hernia, accounting for approximately 1% of all internal having type II lesser omental hernia. Analysis of

Fig. 1 Abdominal CT images. a There is distention of the small intestine in the distal, ventral part of the distorted stomach, accumulated liquid
around the liver; and reduced enhancement in the intestinal mucosa; (b) The small intestine is prolapsed through the defected lesser omentum,
as denoted by the arrows; (c) These is dislocation of the blood vessels of the small intestine and distorted stomach, as indicated by arrow
Liu et al. BMC Surgery (2020) 20:14 Page 3 of 5

Fig. 2 Images of the findings during laparotomy. a A 200-cm segment of the small intestine protruded from the lesser retrogastric curvature of
the stomach to a defected lesser omentum; (b) A defected lesser omentum, of approximately 3 × 4 cm in size, was visualized

causative factors indicated that defects in the lesser mortality rate as high as 75% [14]. Therefore, early diagno-
omentum were caused by congenital factors in six cases sis of intra-abdominal hernia and the performance of the
[3–6, 9, 10], while 3 cases were caused by previous ab- appropriate surgical procedures (e.g., removal of ischemic
dominal surgeries [7, 8], and the remaining cases were intestinal fragments and repair of the orifice of intra-
caused by unidentified factors. Our patient underwent a abdominal hernia) are particularly important. The charac-
total colectomy approximately 2 years before the onset teristic symptoms of this condition include severe and acute
of the lesser omental hernia. Notably, similarities were abdominal pain. In the diagnosis of intra-abdominal hernia,
observed in the abnormal anatomical basis for the devel- the plain abdominal film has little value, while abdominal
opment of lesser omental hernia between Case 7 and CT scanning is of value [15]. In fact, enhanced CT is able
Case 11, Case 4 and Case 8, Case 5, and the present to determine the blood flow of the intestine and the shape
case. Because of this, Type II lesser omental hernia was of the mesenteric vessels, thereby improving the diagnosis
further divided into the following three subtypes: (1) accuracy of intra-abdominal hernia and assisting in an
Type II a is characterized by a combined defect in the evaluation of the intestinal necrosis. Based upon the ab-
ligamenta gastrocolicum. Case 7 and Case 11 are classi- dominal CT findings of the cases that were diagnosed pre-
fied as being Type II a; (2) Type II b is characterized by operatively, including ours (Table 1), the specific features of
a combined defect in the mesocolon transversum. Case abdominal CT in cases of lesser omental hernia are sum-
4 and Case 8 were defined as being Type II b; (3) Type marized as follows: (1) Dilated bowel loops are located in
II c is characterized by openness in the posterior wall of the ventral part of the stomach; (2) Mesenterium are gath-
the omental sac. Case 5 and the present were classified ered in the lesser curvature of the stomach, where the her-
as being Type II c. It merits the attention that the de- nia ring is also present; (3) The stomach is forced to
fects in Type II c lesser omental hernia is likely to be become distorted and relocated, and similar changes may
caused by previous abdominal surgery, resulting in an occur in the surrounding organs (e.g., spleen, transverse
abnormal anatomic basis for the formation of the lesser colon). Besides, it is also important to explore the epidemi-
omental hernia. Therefore, it is highly recommended ology of lesser omental hernia after total colectomy in par-
that surgeons carefully examine the small omentum be- ticular the incidence in order to know if total colectomy
fore the closure of the abdomen in abdominal surgery, increases the risk of occurrence of this type of hernia by
to avoid postoperative complications, such as the lesser chance or iatrogenic forms.
omentum hernia, as observed in the present case. Taken together, the cause of lesser omental hernia can
Because lesser omental hernia can cause acute intestinal be congenital or acquired. As the use of abdominal sur-
obstruction and other severe clinical conditions, accurate gery is continuously increasing, the risk of developing
diagnosis and timely treatment are essential to improve the abdominal surgery-associated complications, such as
clinical outcomes of patients. This is exceptionally import- lesser omental hernia, is on the rise. Thus, careful exam-
ant for elderly patients, such as the patient in the present ination of the small omentum before the closure of the
case, who was 73 years of age. It is generally accepted that abdomen is expected to reduce the occurrence of these
an intra-abdominal hernia impairs the relocation of the ab- abdominal surgery-associated complications. The char-
normal contents to the original location or the ability to acteristic findings of abdominal CT in the present case
self-repair. The intra-abdominal hernia can cause strangu- and those of previous cases may help other clinicians to
lated intestinal obstruction, intestinal necrosis, infectious obtain accurate diagnoses of lesser omentum hernia in
shock, and even multiple organ failure, with a reported the future.
Table 1 Summary of previously reported cases with lesser omental hernia
Case Refs. Year Age Gender Type History of abdominal Intraoperative findings CT findings Herniated Surgical method
surgery organ
Bowel Orifice
resection closure
Liu et al. BMC Surgery

1 Li A[3] 2017 38 F I – Malrotation of the midgut, dissociation No CT examination Ileum + +

of Ileocecal, endometriosis
2 Rathnakar 2016 54 M I – Defect in the lesser omentus (3 × 2 cm No CT examination Jejunum – +
SK[4] in size)
3 Wang W[5] 2016 62 F I – Defects in ligamentum Small intestine and mesostenium Jejunum + +
hepatogastricum (3 × 2 cm in size) vessels gathered in the lesser
(2020) 20:14

complicated with defects in the gastric curvature

mesocolon transversum, greater omentum,
4 Kundaragi 2014 55 M II – Defects in ligamentum hepatogastricum Distorted stomach became thinner Small – +
NG[6] (4 cm in diameter), complicated with defect and longer; colon transversum was intestine
in the mesocolon transversum relocated, dilated bowel loops were
visible in the ventral part of the stomach
5 Konishi 2014 42 M II Total colectomy Defect in the lesser omentum (5 cm in air-fluid levels above the stomach Jejunum – +
T[7] diameter)
dilated bowel loops were located in the
ventral part of the stomach and the
mesostenium vessels gathered in the
lesser curvature of the stomach
6 Masubuchi 2013 57 F II Left hemi-colectomy Defects in the ligamentum Distorted stomach, obstructed bowel loops Ileum – +
S[8] hepatogastricum (4 cm in diameter), located in the ventral part of the distal stomach
complicated with the mesocolon
transversum (5 cm in diameter)
7 Min JS[9] 2009 47 F II – Defects in ligamentum hepatogastricum Dilated jejunum with liquid accumulation, Jejunum + +
and ligamenta gastrocolicum mesostenium perforated through the defected
greater omentum
8 Bahadori 2001 14 F II Appendectomy Defects in the lesser omentum and Distortion and relocation of the stomach Small
K[10] mesocolon transversum intestine
9 Duarte 1996 36 M I Unknown Defect in the lesser omentum No CT examination Ileum + +
GG[11]
10 Tran TL[12] 1990 24 M I Unknown Defect in ligamentum hepatogastricum Dilated bowel loops were visible within the Jejunum + +
(4 cm in diameter) omental burs, the spleen was relocated.
11 Yasuda 1984 20 M II Unknown Defects in ligamentum hepatogastricum Upper abdominal air-fluid levels Small + +
S[13] (4 cm in diameter) and ligamenta gastrocolicum intestine
12 Current 2018 73 F II Subtotal colectomy Defect in ligamentum hepatogastricum Distorted stomach, perforated mesostenium Jejunum + +
case (4 cm in diameter) through the defected lesser omentum, dilated
bowel loops located in the ventral part of the
distal stomach and relocated mesostenium
vessels
Page 4 of 5
Liu et al. BMC Surgery (2020) 20:14 Page 5 of 5

Abbreviations 11. Duarte GG, Fontes B, Poggetti RS, et al. Strangulated internal hernia through
CIC: Chronic idiopathic constipation (CIC); CT: Computed tomography; the lesser omentum with intestinal necrosis: a case report. Sao Paulo Med J.
IPAA: Ileal pouch-anal anastomosis; LA: Lactic acid; WBC: White blood cell 2002;02:120(3).
12. Tran TL, Regan F, al-Kutoubi MA, et al. Computed tomography of lesser sac
Acknowledgments hernia through the gastrohepatic omentum. Br J Radiol. 1991;64(760):372–4.
Not applicable. 13. Yasuda S, Inatsugi N, Sakurai T, et al. A case of intestinal obstruction due to
a hernia traversing the lesser sac. Jpn J Surg. 1989;19(1):70–3.
Authors’ contributions 14. Ghiassi S, Nguyen SQ, Divino CM, Byrn JC, Schlager A. Internal hernias:
The authors contributed to this study as follows: SJ contributed to the clinical findings, management, and outcomes in 49 nonbariatric cases. J
conception and design and critical revision. LZC contributed to the writing Gastrointest Surg. 2007;11(3):291–5.
acquisition of the data. HL and YJ contributed to writing and critical revision. 15. Lanzetta MM, Masserelli A, Addeo G. etInternal hernias: a difficult diagnostic
XZH contributed to the review of the literature. All authors read and challenge. Review of CT signs and clinical findings. Acta Biomed. 2019;90(5-
approved the final manuscript. S):20–37.

Funding Publisher’s Note

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published maps and institutional affiliations.
Availability of data and materials
All data and materials are available in case of a request.

Ethics approval and consent to participate

Ethics approval and consent was waived because this study is a case report
and a review of the literature.

Consent for publication

Written informed consent for publication of clinical data and clinical images
was obtained from the patient.

Competing interests
The authors declare that they have no competing interests.

Author details
1
Department of Gastrointestinal Surgery, The First Hospital of Jilin University,
71 Xinmin Ave., Changchun 130021, Jilin, China. 2Department of
Hepatobiliary and pancreatic Surgery, The First Hospital of Jilin University,
Changchun 130021, Jilin, China. 3Department of Gastrointestinal Surgery,
China-Japan Union Hospital of Jilin University, Changchun 130021, Jilin,
China.

Received: 14 March 2019 Accepted: 13 December 2019

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