Paraduodenal hernia: a treatable cause of upper gastrointestinal tract symptoms

Right paraduodenal hernia, classification, and selection of surgical methods: a case report and review of the literature

BACKGROUND

Considering that right paraduodenal hernia is a rare internal hernia with abnormal anatomy and is often encountered during an emergency, surgeons may lack knowledge about it and choose incorrect treatment. Thus, this case report is a helpful complement to the few previously reported cases of right paraduodenal hernia. Additionally, we reviewed all the reported right paraduodenal hernia cases and proposed appropriate surgical strategies according to different anatomical features.

CASE PRESENTATION

The case involved a 33-year-old Chinese male patient who was admitted to the hospital due to abdominal pain. The patient was initially diagnosed with small bowel obstruction, and conservative treatment failed. An emergency operation was arranged, during which a diagnosis of right paraduodenal hernia was made instead. After surgery, the patient recovered well without abdominal pain for 2 years.

CONCLUSION

Although right paraduodenal hernia accounts only for a small proportion of paraduodenal hernia, its anatomical characteristics can vary considerably. We divided right paraduodenal hernia into three types, with each type requiring a different surgical strategy.

Internal hernia caused by a congenital peritoneal defect in the vesicouterine space

Internal hernias are protrusions of viscera that can cause obstructions such as small bowel obstruction (SBO). Diagnosis can be challenging, as they usually come with an atypical presentation. We report on a case of a woman in her early 40s, with no history of surgery or chronic illnesses, which came with abdominal pain associated with vomiting. CT scan revealed obstructed small bowel. On exploratory laparoscopy, an internal hernia through a peritoneal defect in the vesicouterine space was found, entrapping a limb of the jejunum. The entrapped loop of the small bowel was freed, the ischaemic part was resected, and the defect was closed. Our case presents the second reported case of a congenital vesicouterine defect causing SBO. It is important to consider patients presenting with SBO as a case of congenital peritoneal defect if they had no previous surgeries.

Right-sided paraduodenal hernia with malrotation - A case report

Introduction

Paraduodenal hernia is a rare cause of internal hernia. It is the herniation of small bowel through a peritoneal sac in the duodenum. It occurs due to incomplete rotation and fixation abnormalities of the primitive midgut during fetal development. We report a case of right sided paraduodenal hernia in an adult male.

Case presentation

This is a case of 36-year-old gentleman who presented with complaints of abdominal fullness and upper abdominal pain for 1.5 months and 7 to 8 episodes of vomiting. CT scan of abdomen gave an impression of right-sided paraduodenal hernia. Exploratory laparotomy with hernia repair was performed and patient was discharged without complications.

Discussion

Right sided paraduodenal hernia is the protrusion of viscera through the fossa of Waldeyer. It is frequently associated with malrotation and strangulation. Its diagnosis is frequently delayed. Symptoms are non-specific and may need laparotomy for diagnosis. Technique of choice for surgical management remains inconclusive.

Conclusion

Paraduodenal hernias are frequently diagnosed late or incidentally because of vague symptoms. They are rarer and carry higher lifetime risk of strangulation and bowel obstruction. Surgical management is necessary after diagnosis.

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Paraduodenal hernia is a rare case of internal hernia due to abnormalities in fetal development.

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Right sided paraduodenal hernia is three times rarer than its left sided counterpart.

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Symptoms are vague and nonspecific which can delay the diagnosis with the risk for strangulation and bowel necrosis.

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Treatment is by hernia reduction with defect repair or widening.

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.

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.

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.

Congenital left paraduodenal hernia causing chronic abdominal pain and abdominal catastrophe

Paraduodenal hernias are the most common type of congenital internal hernia. Because of its overall rare incidence, this entity is often overlooked during initial assessment of the patient. Lack of specific diagnostic criteria also makes diagnosis exceedingly difficult, and the resulting diagnostic delays can lead to tragic outcomes for patients. Despite these perceived barriers to timely diagnosis, there may be specific radiographic findings that, when combined with the appropriate constellation of clinical symptoms, would aid in diagnosis. This patient first presented at 8 years of age with vague symptoms of postprandial emesis, chronic abdominal pain, nausea, and syncope. Over the span of 6 years he was evaluated 2 to 3 times a year with similar complaints, all of which quickly resolved spontaneously. He underwent multiple laboratory, imaging, and endoscopic studies, which were nondiagnostic. It was not until he developed signs of a high-grade obstruction and extremis that he was found to have a large left paraduodenal hernia that had volvulized around the superior mesenteric axis. This resulted in the loss of the entire superior mesenteric axis distribution of the small and large intestine and necrosis of the duodenum. In cases of chronic intermittent obstruction without clear etiology, careful attention and consideration should be given to the constellation of symptoms, imaging studies, and potential use of diagnostic laparoscopy. Increased vigilance by primary care and consulting physicians is necessary to detect this rare but readily correctable condition.

Right paraduodenal hernia successfully treated with laparoscopic surgery

A 23-year-old Japanese man presented with a history of sudden-onset right abdominal pain accompanied by nausea and vomiting. Contrast-enhanced CT showed a large cluster on the right side of the retroperitoneum, with most of the small bowel incarcerated. The patient was diagnosed with small bowel obstruction caused by a right paraduodenal hernia, and emergency laparoscopic surgery was performed. The large retroperitoneal cluster on the right side contained almost all segments of the small bowel, although the incarcerated bowel showed no evidence of volvulus or ischemia. The bowel was reduced, and the hernia orifice was closed. The patient made good progress and was discharged 7 days after surgery. We herein report an acute case of right paraduodenal hernia with small bowel obstruction that was successfully treated with emergency laparoscopic surgery. With an early preoperative diagnosis, laparoscopic surgery is appropriate for the treatment of right paraduodenal hernia.

Left paraduodenal hernia: A rare cause of acute abdomen

Paraduodenal hernia is a rare congenital anomaly that arises from an error of rotation of the midgut. The duodenum and the small intestine become trapped in a sac which is lined by the peritoneum, behind the mesentery of the colon, either to the right or left of the midline. It is therfore a rare and potentially life-threatening condition that can cause intestinal obstruction progressing to strangulation and perforation. We report a case of a 55-year-old patient presenting a left paraduodenal hernia diagnosed intraoperatively after being operated on in the emergency setting for acute abdomen. The small bowel was twisted upon its mesentery and was entrapped in a large left paraduodenal space. Fortunately, once the bowel was reduced from the paraduodenal space, the blood flow was reestablished and the small bowel resumed a proper functioning. The mouth of the sac was obliterated by suture opposition to the posterior wall. The patient's subsequent hospital course was uneventful, and he was discharged in satisfactory condition 4 days postoperatively.

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.

Laparoscopic repair of a right para duodenal hernia

Para duodenal hernia is among the uncommon and rare causes of intestinal obstruction, but it is the most common type of internal hernia in abdomen and accounts for more than half of cases that do occur. Here, we are reporting a case of right Para duodenal hernia, reduced and repaired laparoscopically. This thirteen year old girl presented to us with features of small bowel obstruction of two days duration. Plain abdominal X-ray showed multiple fluid levels confined to right side of abdomen. A diagnostic laparoscopy was done under General Anaesthesia. Right Para duodenal hernia was found with small bowel confined to the right side between the ascending colon and hepatic flexure of colon. Laparoscopic reduction of contents of the hernia was done starting from the Ileocaecal junction. Hernial opening was closed laparoscopically with nonabsorbable suture. Patient is quite well till date and has had no recurrence of symptoms

A massive left paraduodenal fossa hernia as an unusual cause of small bowel obstruction

We present our experience in diagnosing and treating a case of a massive left paraduodenal fossa hernia, containing over 30% of the small bowel, presenting with a history of recurrent incomplete small bowel obstruction.

Left paraduodenal hernia incidentally diagnosed during operation for transverse colon cancer

We report the case of a patient with paraduodenal hernia diagnosed incidentally during an operation for transverse colon cancer. The patient was a 77-year-old woman who complained of dizziness. Laboratory data revealed no abnormal findings except slight anemia. Barium enema and colonoscopic examination revealed an irregular surfaced mass, about 5.0 cm in size, located near the flexure of the spleen of the transverse colon. A biopsy of the mass was performed, and a moderately differentiated adenocarcinoma was diagnosed. In April 2009, following the diagnosis of transverse colon cancer, laparotomy was performed, which revealed that a few loops of the jejunum were herniated through the orifice into the space posterior to the transverse mesocolon. Moreover, the jejunal loops were located right between a shifted left branch of the middle colic artery and ascending left colic artery. There were no ischemic changes in the jejunum. These findings were consistent with a left paraduodenal hernia associated with transverse colon cancer. The scheduled left hemicolectomy was performed in addition to a radical operation of the left paraduodenal hernia. The abdominal computed tomography (CT) images were reviewed postoperatively. The scan projection radiogram obtained by CT revealed a packing of jejunal loops in the middle of the abdomen. Abdominal CT revealed ascending left colic artery at the left edge of a packing of jejunal loops. The patient was discharged from our hospital 14 days after the surgery without any complications. Left paraduodenal hernias are rare and constitute less than 0.4% of all intestinal obstructions. Retrospectively reviewed, the preoperative CT is suggestive. In addition to the packing of jejunal loops in the middle of the abdomen, ascending left colic artery was clearly observed at the left edge of the packing of jejunal loops, which indicates left paraduodenal hernia.

Left laparoscopic paraduodenal hernia repair

BACKGROUND

An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Paraduodenal hernia is by far the most common form of congenital internal hernia, making up 53% of all reported cases. In recent years, as surgeons have become more comfortable with laparoscopic techniques, they are performing an increasing number of these procedures laparoscopically.

METHODS

To highlight the technical steps of this technique, the case of a patient with a left paraduodenal hernia and a video of the laparoscopic repair are presented. Additionally, a PubMed search of the English medical literature was conducted using the search words "laparoscopic," "paraduodenal," and "hernia" as filters. The cases of laparoscopic paraduodenal hernia repair in the literature to date recording data on technique, complications, and hospital course were reviewed.

RESULTS

In addition to the case described in this report, 14 cases of laparoscopic paraduodenal hernia were described in 10 published reports. Of the 15 cases, 11 (73%) were left-sided, likely representing the relative incidence of these cases. The hernia defect was closed in 10 (77%) of the 13 cases for which the repair method was described, whereas the defect was widely opened in the remaining cases. One report described an operative complication (6.7%), an internal mesenteric vein injury, and one recurrence (6.7%) occurred 18 months after surgery in the direct defect closure group.

CONCLUSION

The current data lead to the conclusion that laparoscopic paraduodenal hernia repair is a safe and feasible approach for selected patients. It can be expected that as surgeons become increasingly comfortable and facile with laparoscopic techniques, paraduodenal hernias and many other causes of acute small bowel obstruction will be increasingly managed laparoscopically.

Laparoscopic repair of paraduodenal hernia: comparison with conventional open repair

Paraduodenal hernia is a congenital internal hernia caused by abnormal retroperitoneal fixation of the intestinal mesentery. The management of paraduodenal hernia consists of reduction of the herniated intestine and repair of the defect. Recently, laparoscopic surgery has been increasingly performed in abdominal procedures. To evaluate the feasibility and efficacy of laparoscopic repair of paraduodenal hernia, we present our experience in 2 cases of laparoscopic repair, compared with 3 other cases treated with conventional open repair; all 5 cases were successfully treated. All patients had symptoms of intestinal obstruction and were diagnosed by preoperative abdominal computed tomography. Two cases were right-sided hernias, and 3 cases were left sided. Among them, 2 patients with left-sided paraduodenal hernia underwent laparoscopic reduction (LR group) of the herniated small bowel, and the other 3 cases underwent open reduction (OR group). In the LR group, the duration of hospital stay, time to first flatus, and time to first intake of a soft diet were shorter than in the OR group. Thus, with an accurate preoperative diagnosis of paraduodenal hernia, laparoscopic surgery may be a feasible and efficient procedure, with good postoperative outcomes.

Laparoscopic management of paraduodenal hernias: mesh and mesh-less repairs. A report of four cases

BACKGROUND

Paraduodenal hernias are the most common form of internal hernias. There are few reports in the literature, with the total number of reported cases being less than 500. We report four patients with paraduodenal hernias causing intestinal obstruction.

MATERIALS AND METHODS

All of the four patients with paraduodenal hernias presented with features of intestinal obstruction. A clinical diagnosis was not made in any of the cases, and computed tomography (CT) scanning was performed to confirm this. They were all successfully managed by a laparoscopic repair.

RESULTS

The operating time was 55-72 mins. Postoperatively, three patients recovered uneventfully, while one patient had ileus for 3 days and, thereafter, recovered spontaneously. Hospital stay was in the range 2-6 days. There were no conversions. One patient had recurrent paraduodenal hernia, for which a laparoscopic mesh repair was successfully performed.

DISCUSSION

The mechanism of the herniation is thought to be a defective rotation of the superior mesenteric vein during embryonic development. Paraduodenal hernias are not high on the list of differentials for bowel obstruction. Some form of surgery is mandatory for all cases. The inferior mesenteric vein has to be sacrificed in some cases to facilitate reduction of the hernia contents. A mesh repair is reserved for large defects and recurrent hernias. Laparoscopic repair has been infrequently reported in the literature. Based on our experience, the laparoscopic approach seems to be effective in the repair of paraduodenal hernias. It carries all of the benefits of minimal access surgery, while providing a sound repair.

Volvulus of the small intestine caused by right paraduodenal hernia: a case report

This report describes a very rare case of right paraduodenal hernia presenting as volvulus of nonherniated small intestine. A 12-year-old boy presented with sudden onset of lower abdominal pain, and emergency laparotomy was performed on a diagnosis of small intestinal obstruction. Laparotomy confirmed right paraduodenal hernia and volvulus of the small intestine out of the hernia sac.