|Year : 2014 | Volume
| Issue : 3 | Page : 96-98
Paraduodenal hernia: A case report and review of the literature
M Correia, D Amonkar, P Audi, O Vaz, D Samant
Department of General Surgery, Goa Medical College, Bambolim, Goa, India
|Date of Web Publication||15-Dec-2014|
Resicom Elite, Flat C 02, Off Kadamba Depot Road, Alto Porvorim, Bardez, Goa 403 521
Source of Support: None, Conflict of Interest: None
We present the case of a 43-year-old woman who presented to our emergency department with progressive left sided abdominal pain of 1 day duration. She had a past history of bilateral renal calculi for which she was receiving treatment. Computed tomography scan revealed a sac-like mass of small bowel loops to the left of the ligament of Treitz, consistent with the diagnosis of a left paraduodenal hernia. At laparotomy, a left paraduodenal hernia with incarceration of small bowel loops were found, the herniated loops were reduced and the hernial orifice closed. The patient had an uneventful postoperative stay in hospital. Since the discharge from hospital, she has followed up on many occasions and there has been no recurrence of pain. With modern imaging modalities, early and correct diagnosis is possible. Due to the risk of obstruction and strangulation, surgical treatment is indicated. Early intervention increases the likelihood of a favorable outcome. Paraduodenal hernias are a rare congenital anomaly which arises from an error of the rotation of the midgut.
Keywords: Internal hernia, intestinal obstruction, paraduodenal hernia
|How to cite this article:|
Correia M, Amonkar D, Audi P, Vaz O, Samant D. Paraduodenal hernia: A case report and review of the literature
. Saudi Surg J 2014;2:96-8
| Introduction|| |
Paraduodenal hernias are uncommon and account for <1% of all cases of small bowel obstruction. They are associated with a high lifetime risk of causing obstruction and in these cases, mortality rate is up to20%, probably due to missed diagnosis.  Internal hernias are a rare cause for intestinal obstruction. Para duodenal hernias constitute approximately 53% of all internal hernias.  Several studies have demonstrated the value of computed tomography (CT) in confirming the diagnosis and revealing the cause of small bowel obstruction, with a sensitivity of 94-100% and an accuracy of 90-95%.  If diagnosed, herniated loops should be reduced, and the hernia orifice closed or widened. In this case report, we report the case of a 43-year-old woman who had an acute small bowel obstruction caused by a left paraduodenal hernia.
| Case Report|| |
S N, a 43-year-old female patient presented to the emergency department with 1 day history of severe left sided colicky abdominal pain and vomiting. She had a normal stool the same morning, and there was no fever, diarrhea or urinary symptoms. The pain started a few hours earlier and involved the left abdomen. The pain did not radiate, and there were no provoking or relieving factors. On examination, the patient had no tachycardia. There was tenderness and guarding with rigidity in the left hypochondrium, lumbar and iliac fossae. A lumpish feel in the left lumbar region was felt. The rest of the abdomen was soft, and there were no signs of peritonitis. In view of her history of bilateral renal calculi, a diagnosis of left pyonephrosis was kept in mind. Plain abdominal film did not show free air under the diaphragm but dilated small bowel loops were seen on the left side of the abdomen. CT scan revealed an encapsulated sac-like mass of small bowel loops to the left of the ligament of Treitz consistent with the diagnosis of a left paraduodenal hernia [Figure 1].
|Figure 1: Coronal section of computed tomography scan showing bowel loops in a sac (the typical bag of bowel appearance) indicated by white arrow|
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A laparotomy was performed, and a left paraduodenal hernia with incarceration of small bowel loops was found [Figure 2]. All herniated bowel loops were vital and were reduced. The hernia orifice was closed with non-absorbable sutures [Figure 3]. The postoperative course was uncomplicated and uneventful, and the patient has not experienced abdominal pain since leaving the hospital.
|Figure 3: Neck of sac after extracting small bowel loops indicated by the white arrow|
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| Discussion|| |
Internal hernias, herniation of a segment of intestine into an intraperitoneal fossa, are uncommon causes of intestinal obstruction and are difficult to diagnose preoperatively. It may be discovered as an incidental finding at laparotomy or may be the cause of acute small bowel obstruction which can go on to strangulation and perforation. Its presence may also lead to confusion and errors in the performance of other abdominal operations, although itself not the cause of any symptoms.
Internal abdominal hernias are defined as the herniation of a viscus through an intraperitoneal orifice or aperture within the confines of the peritoneal cavity.  These hernias give rise to chronic dyspeptic symptoms or be asymptomatic and only found at autopsy. More than 50% of internal hernias reported in the literature have been paraduodenal.  Seventy-five percent of para-duodenal hernias occur on the left while 25% occur on the right. They originate at the fossa of Landzert, which is just lateral to the fourth segment of the duodenum and behind the inferior mesenteric vein and ascending left colic artery. 
The most accepted mechanism of left paraduodenal hernias involves malrotation of the midgut during the early weeks of gestation. In the 5 th week of embryonic development, the rapidly elongating midgut herniates into the umbilical cord. Later, the herniated midgut undergoes a counter-clockwise rotation of 90° around the superior mesenteric artery (SMA), leaving the prearterial limb on the left side. The herniated intestinal loop, first the prearterial then the postarterial limb, returns to the abdominal cavity by the 10 th week. During this process, the intestinal loop undergoes another 180° counterclockwise rotation. In the end, the prearterial limb lies left to the SMA and the postarterial limb lies superior and right to the SMA. 
Under normal circumstances, fusion of the mesocolon with the peritoneum of the body wall follows this process. Failure of the fusion to take place in time leaves a potential space (the fossa of Landzert) behind the mesocolon. While rotating into the peritoneal cavity, the mesentery fails to fuse with the parietal peritoneum creating a hernia orifice. Small bowel loops can become trapped between the mesocolon and the posterior abdominal wall when they herniate through this orifice, lateral to the fourth segment of the duodenum, the paraduodenal fossa of Landzert. ,
The left Para duodenal fossa of Landzert present in 2% of autopsy cases is situated to the left of ascending or fourth part of the duodenum and is caused by the raising up of a peritoneal fold by the inferior mesenteric vein as it runs along the lateral side of fossa and then above it.  Small intestine may herniate through the orifice posteriorly and downward to the left, lateral to the ascending limb of duodenum extending into descending mesocolon and left part of the transverse mesocolon. The free edge of hernia thus contains the inferior mesenteric vein and ascending left colic artery. 
Because internal hernias are not detectable on physical examination, imaging is relied upon for preoperative diagnosis. Since herniation is often intermittent, the radiographic diagnosis therefore depends on the time of imaging. Plain film radiographic findings are usually nonspecific. UGI-small bowel follow-through, CT scan and occasionally ultrasound may make the diagnosis by identifying isolated bowel, "a bag of bowel", in the hernia sac.
Radiographically, left paraduodenal hernias present as an ovoid conglomeration of jejunal loops in the left upper quadrant, often displacing the stomach superiorly and the transverse colon inferiorly. 
Treatment of left paraduodenal hernia requires surgery. The typical appearance during surgery is that of an "empty abdomen" with only the last segment of the ileum present in the abdominal cavity while other small bowel loops are entrapped in the hernia sac.  The herniated small bowel loops should be reduced and the hernia orifice closed with non-absorbable sutures. A different technique is to widen the hernia orifice to prevent future incarceration of bowel loops. Often, there is a close anatomical relationship between the inferior mesenteric vessels which bound the hernia anteriorly, and the hernia orifice and care should be taken not to injure these vessels. Although Bartlett indicated that these vessels can be divided without compromising blood supply to the colon, they should be preserved whenever possible. 
Studies have revealed that when the diagnosis is made preoperatively, a laparoscopic approach is possible. Since the first laparoscopic repair by Uematsu in 1998, the laparoscopic approach has been a way of diagnosis and repair for paraduodenal hernias.  Intestinal resection is needed in cases of strangulation and gangrene.
In our patient, we performed a laparotomy because of lack of experience with paraduodenal hernias and their treatment. A high index of suspicion along with excellent imaging like CT scan helps in arriving at a correct preoperative diagnosis. Early surgical intervention is critical in avoiding the morbidity and mortality associated with paraduodenal hernias.
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[Figure 1], [Figure 2], [Figure 3]