The duodenal fossae: anatomic study and clinical correlations

Mesocolic hernia, a case series

INTRODUCTION AND IMPORTANCE

Paraduodenal hernias are difficult to diagnose due to their unusual presentation. Herein, five new cases are added to the literature.

CASE PRESENTATION

Four male and one female child complained of paraduodenal hernias, two on the right side and three on the left side. The intestinal part that herniated inside the hernia sac was also malrotated in four patients. One patient had Meckel's diverticulum with a herniated intestine. One infant had extrahepatic biliary disease, a single atrium, polysplenia, intestinal malrotation, and a left paraduodenal hernia. Exploratory labarotomy was done for reduction of the intestine, reorientation, and repair of hernia orifices.

CLINICAL DISCUSSION

Paraduodenal hernia is a component of malrotation. Cautious dissection of the hernia orifice is required to keep away from injuries to the inferior mesenteric vein or left colic artery in the course of the restoration of the left paraduodenal hernia. Also, the superior mesenteric vessels may be injured in the course of the restoration of the right paraduodenal hernia.

CONCLUSION

There is a correlation between the occurrence of PDH with malrotation. The diagnosis of malrotation can be made with an ultrasound abdomen; however, it is true that ultrasound cannot make a confirmed diagnosis in all patients. Once the diagnosis of a mesocolic hernia has occurred, surgical repair is mandatory by closure of the defect.

Morphological features of the mouse duodenocolic fold in foetus and adult

For the mechanism of duodenojejunal flexure (DJF) morphogenesis in mice, we consider the gut tube itself and the gut mesentery as important players. In this study, we focussed on the morphological features of the gut mesentery around the mouse duodenum, especially the duodenocolic fold at embryonic day (E) 18.5 and the adult phase. The duodenocolic fold, a sheet of the mesentery, was located between the entire ascending duodenum and the descending colon. At E18.5, in the cranial area near the DJF, the duodenocolic fold joined both the mesocolon and the mesojejunal part of the root of the mesentery. In the middle and caudal areas, the duodenocolic fold joined the mesocolon. Interestingly, along with the ascending duodenum, the duodenocolic fold contained a smooth muscle bundle. The smooth muscle bundle continued from the outer muscular layer of the middle to the caudal part of the ascending duodenum. The three-dimensional imaging of the foetal duodenocolic fold revealed that the smooth muscle bundle had short and long apexes towards the proximal and distal parts of the root of the mesentery, respectively. At the adult phase, the duodenocolic fold had a much thinner connective tissue with a larger surface area in comparison with the duodenocolic fold at E18.5. The adult duodenocolic fold also contained the smooth muscle bundle which was similar to the foetal duodenocolic fold. A part of the duodenocolic fold connecting to the mesojejunal part of the root of the mesentery seemed to be homologous to the superior duodenal fold in humans, known as the duodenojejunal fold; by contrast, most of the duodenocolic fold seemed to be homologous to the inferior duodenal fold in humans, known as the duodenomesocolic fold. The smooth muscle bundle in the mouse duodenocolic fold seemed to play a role in keeping the ascending duodenum in the abdominal cavity because the duodenum in animals did not belong to a retroperitoneal organ in contrast to humans owing to the difference in the direction of gravity on the abdominal organs between mice and humans. Moreover, the smooth muscle bundle shared common and uncommon points in its location and nerve supply to the suspensory muscle of the duodenum in humans, known as the ligament of Treitz. This study had insufficient evidence that the smooth muscle bundle of the mouse duodenocolic fold was homologous to the suspensory muscle of the duodenum in humans. In conclusion, this study revealed the detailed structure of the mouse duodenocolic fold, including the relationship between the fold and other mesenteries. Particularly, the smooth muscle bundle is a specific feature of the mouse duodenocolic fold and might play several roles in DJF morphogenesis, especially the ascending duodenum and the caudal duodenal flexure during development.

Left Paraduodenal Hernia Treated With Single-Incision Laparoscopic Surgery: Report of a Case

Paraduodenal hernia is traditionally repaired via conventional laparotomy. Recently, several reports described the repair of paraduodenal hernia via laparoscopic surgery with multiple ports. Due to development of the technique and devices for laparoscopic surgery, single-incision laparoscopic surgery (SILS) has been applied to various operations, including cholecystectomy, appendectomy, and procedures for colorectal cancer. Here, we report treatment of a left paraduodenal hernia via SILS. A 23-year-old man presented with abrupt onset of abdominal pain, nausea, and vomiting. Computed tomography revealed a mass of intestinal loops enveloped by a thin capsule on the left of the abdominal cavity. Blood circulation in the jejunal loops was preserved, and no dilatation of the jejunum was observed. Physical and radiographic examination indicated the possibility of left paraduodenal hernia; we performed paraduodenal hernia repair using SILS. After we confirmed that there was no strangulation or gangrenous change in the bowel on laparoscopic examination, we reduced the incarcerated jejunum loops via an atraumatic method. The postoperative course was uneventful, and the patient was discharged 8 days after the operation. This disease affects relatively young patients, rendering this operation attractive from the viewpoint of cosmetic benefits and minimal invasion. Paraduodenal hernia repair via SILS is feasible, safe, and may constitute an alternative method for paraduodenal hernia without necrotic change.

Large left paraduodenal hernia with intestinal ischemia: a case report and literature review

A left paraduodenal hernia is a rare type of internal hernia but the most common type of peritoneal recess hernia. Preoperative diagnosis of a left paraduodenal hernia is difficult because of its nonspecific clinical manifestations, and it is often confused with other causes of acute abdomen. Diagnosis is therefore often delayed, resulting in serious clinical outcomes. We herein report a case of a large paraduodenal hernia with small intestinal obstruction and ischemia without abdominal pain. The patient was successfully discharged after emergency hernia repair. This case reveals the importance of diagnosing a left paraduodenal hernia with or without abdominal pain, especially in patients with no history of abdominal surgery.

Paraduodenal hernias: a systematic review of the literature

PURPOSE

Paraduodenal hernias (PDH), also called mesocolic hernias, account for up to 53% of all internal hernias, but they cause only 0.2-0.9% of all cases of intestinal obstruction. This is the first systematic review of all reported cases so far, investigating their clinical presentation, radiological imaging, and treatment outcomes.

METHODS

After a detailed search in PubMed and Medline, using the keywords "paraduodenal hernia", 115 studies matched our criteria. A review of these reports was conducted and the full texts were examined.

RESULTS

A total of 159 patients were included in our analysis, with 69.8% and 30.2% of them suffering from either a left or a right PDH, respectively. Mean age at diagnosis was 44.1 years, with a 2/1 male/female ratio. PDH were associated with non-specific symptoms and signs; abdominal pain being the most common. Computed tomography (CT) scan of the abdomen was the most frequently used diagnostic modality. Regardless of PDH localization, all patients were operated on, with approximately one-third of them undergoing a laparoscopic operation, which was associated with a significantly decreased morbidity rate as well as length of hospital stay, compared with the open repair.

CONCLUSIONS

PDH are not usually associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of knowledge and clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair, seeming to be the optimum treatment strategy.

Clinical importance of duodenal recesses with special reference to internal hernias

INTRODUCTION

The detailed knowledge of the peritoneal recesses has great significance with respect to internal hernias. The recesses are usually related to rotation and adhesion of abdominal viscera to the posterior abdominal wall and/or the presence of retroperitoneal vessels which raises the serosal fold. The duodenal recesses are usually related to the 3^rd and 4^th parts of the duodenum. Internal hernias with respect to these recesses are difficult to diagnose clinically and usually noticed at the time of laparotomy. So, the knowledge of these recesses can be valuable to abdominal surgeons.

MATERIAL AND METHODS

The present study was conducted in 100 cases including 10 cadavers, 45 post mortem cases and 45 cases undergoing laparotomy.

RESULTS

We found superior and inferior duodenal recesses in 28% and 52% respectively, paraduodenal in 12%, mesentericoparietal in 3%, retroduodenal in 2% and duodenojejunal in 18% of cases. Two abnormal duodenojejunal recesses were found, one on the right (instead of the left) of the abdominal aorta, and in the other the opening was directed upwards instead of downwards. The incidence of internal hernias was 3%.

CONCLUSIONS

Thus it was observed that there is low incidence of superior and inferior duodenal recesses, and high incidence of paraduodenal recess. The abnormal recesses might be due to malrotation of the gut. In laparotomy cases, the internal hernia was noticed when the abdomen was opened for intestinal obstruction. The incidence of internal hernia was found to be high.

Timing of Abdominal CT Evaluation Impacts the Diagnosis of Paraduodenal Hernia

Internal hernias are the causes of 0.5 to 5.8 per cent of all cases of small bowel obstruction. Left paraduodenal hernia (PDH) is the most common congenital internal hernia encountered in adults. The symptoms and physical findings associated with PDH are vague and nonspecific before the onset of complicated intestinal obstruction. Diagnoses are most commonly established by CT. This case presentation and review is intended to promote clinicians’ awareness of this unusual but potentially highly morbid condition, discuss CT findings associated with PDH, and illustrate the importance of timing in the acquisition of diagnostic abdominal CT scans.

Giant left paraduodenal hernia

Left paraduodenal hernia (LPDH) is a retrocolic internal hernia of congenital origin that develops through the fossa of Landzert, and extends into the descending mesocolon and left portion of the transverse mesocolon. It carries significant overall risk of mortality, yet delay in diagnosis is not unusual due to subtle and elusive features. Familiarisation with the embryological and anatomical features of this rare hernia is essential for surgical management. This is especially important with respect to vascular anatomy as major mesenteric vessels form intimate relationships with the ventral rim and anterior portion of the hernia. As an illustrative case, we describe our experience with a striking example of LPDH, particularly focusing on the inherent diagnostic challenges and associated critical vascular anatomy. We advocate the role of diagnostic laparoscopy; however caution that decision to safely proceed with laparoscopic repair must occur only with confident identification of the vascular anatomy involved.

Diagnosis and treatment of symptomatic right paraduodenal hernia: report of a case

We report a typical case of right paraduodenal hernia (RPH) and review the literature on the pathogenesis, diagnosis and treatment of this uncommon entity. A 32-year-old woman was hospitalized with acute abdominal cramps, nausea, and vomiting. Computed tomography (CT) findings suggested RPH, which was confirmed by explorative laparoscopy. We performed an open repair by suturing the orifice after reducing the hernia. At her 2-year follow-up, the patient reported complete resolution of her symptoms. Because RPH is rare and its clinical signs are nonspecific, radiological examinations are essential for a correct preoperative diagnosis. CT is currently the most accurate diagnostic tool, but laparoscopy may be necessary to confirm the diagnosis. This hernia can be repaired by simple suturing of the hernial orifice, either laparoscopically or via an open procedure, although several authors consider complete intestinal derotation to be the best option.

Internal hernias: anatomical basis and clinical relevance

The aim of this study was to present and discuss the anatomical basis of internal hernias thanks to our clinical experience of 14 cases. Internal hernias are uncommon cases of acute intestinal obstruction when a viscera protrudes through an intraperitoneal orifice, remaining inside the peritoneal cavity. It excludes iatrogenic post surgical hernias. From an anatomical point of view, three kinds of orifices may be interested. The orifice may be normal: epiploic or omental (Winslow's) foramen, or abnormal through a pathologic transomental hole realizing an internal prolapsus or procidentia, without sac. Or this orifice may be a paranormal peritoneal fossa (para duodenal or retrocaecal) acting as a trap for the bowel: these hernias possess a sac and are considered as true hernias. The clinical diagnosis is always difficult. CT scan can be useful confirming the obstruction and leads to an urgent operation. This retrospective study evaluates diagnosis, management and follow-up according to the type of anatomical orifice and delay of surgery.