A case report of left paraduodenal hernia diagnosed preoperatively and treated laparoscopically

Abstract

Paraduodenal hernia is a rare congenital anomaly; however, it is the most common cause of internal herniation. Clinical findings are often indeterminate. Computerized tomography is usually diagnostic; however, the diagnosis is often made intra-operatively. Paraduodenal hernia carries a risk of incarceration leading to bowel obstruction and strangulation; therefore, it should be repaired surgically when diagnosed. Here we present a case of left PDH that was diagnosed preoperatively and repaired laparoscopically.Keywords: Laparoscopy, paraduodenal, hernia INTRODUCTIONInternal hernias result from the extension of the intestine through a defect within the peritoneum or mesentery (1). They may be either congenital or acquired. Paraduodenal hernia (PDH) is a rare congenital anomaly that results from an error of rotation of the midgut (2). PDHs are the most common form of internal hernias, accounting for 53% of all internal hernias (1, 3). PDHs are difficult to diagnose because the clinical symptoms are variable (4). PDH can begin with symptoms of acute obstruction or recurring abdominal pain (43%) or can be asymptomatic throughout the patient's life. Between 10% and 50% of internal hernias are discovered during unrelated abdominal surgeries or imaging exams and autopsy (5). Preoperative computerized tomography scan of the abdomen is usually diagnostic; however, the diagnosis is often made intra-operatively. Surgical treatment can be performed with traditional open methods or minimally invasive laparoscopic techniques. We describe herein the preoperative radiological diagnosis and successful laparoscopic repair of a left PDH in an adult man. CASE PRESENTATIONA 39-year-old man was admitted to the emergency department with complaints of epigastric cramps and nausea and vomiting that persisted for almost one day. It was known that he had been suffering from similar problems for a long time, and he had applied to 3 different hospitals in the last 10 days. There was no specific finding except for upper left quadrant tenderness. He had no history of abdominal surgery. His vital signs were normal. On his plain abdominal film, vague and limited air-fluid levels and a mass-like lesion were found in the left quadrants. Laboratory results were normal, except his leukocyte count was 11600. He was hospitalized for follow-up. It was noticed that he was comfortable while resting on his left side; however, his pain worsened in the supine position. Encapsulated and moderately dilated small bowel loops were detected in the upper left quadrant between the stomach and pancreas by CT (Figure 1). He was preoperatively diagnosed with left PDH. Four ports were inserted; one 10 mm supraumblical port for the camera, another port 10 mm from the upper left quadrant, and two 5 mm ports in the upper right quadrant. During exploration, left PDH was observed on the left side of Treitz's ligament behind the inferior mesenteric vein. An entrapped jejunum loop of approximately 80 cm was then reduced from the hernia sac into the abdominal cavity with an ...

Open Surgery Treatment of a Rare Cause of Intestinal Obstruction: Left Paradoudenal Hernia

“…In 1935, left paraduodenal hernia was described as a defect involving the fusion of the left colon and mesentery. 6 In this case, the intestine was observed to have completed rotation, so the left paraduodenal hernia was considered as a defect. Hernias on the left side (Waldeyer hole hernia) are 3 times more common than those on the right side (Landzert hole hernia).…”

Paraduodenal Hernia- An Obscure and Perilous Cause of Intestinal Obstruction.

“…Contrast enhanced abdominal CT is the gold standard for diagnosis of PDH. Typical findings in Left PDH include clumped intestinal loops in smooth encapsulated border (Donnelly's border) between stomach and pancreas, above and lateral to the forth part of duodenum, posterior to inferior mesenteric vein [3]. CECT abdomen in right PDH will show conglomerate of small bowel loops in smooth encapsulated border on right side just anterior to the second part of duodenum, posterior to middle colic vein and superior mesenteric vessels.…”

“…Commonest method of repair of hernia defect is primary closure with continuous non-absorbable suture taking care not to injure inferior mesenteric vein in left PDH and Superior mesenteric vessels in right PDH [3]. Other method is wide opening of hernia orifice in avascular plane so that the hernia sac becomes part of general peritoneal cavity [3]. Excision of hernia sac has also been done but is not mandatory [6].…”

“…PDH are difficult to diagnose clinically because of variable and non-specific symptoms. The patient may remain asymptomatic throughout the life or present with recurrent pain abdomen (43%), or may present with symptoms of acute intestinal obstruction [3].…”

Identification and Repair of Left-Sided Paraduodenal Hernia Using Both Laparoscopic and Robotic Techniques

“…Only 50% of patients recall previous nonspecific recurrent abdominal pain [9], typically worse after meals and improved with body position [5]. There will be no specific exam or laboratory findings to differentiate PDH from other pathology [10] beyond elevated inflammatory markers typically associated with worsening bowel ischemia. Mean age at PDH diagnosis is 38.5 years [2], and males are affected three times more frequently than females [9].…”