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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 4  |  Page : 202-204

Paraduodenal hernia


1 Department of General Surgery, NGHA, Riyadh, Saudi Arabia
2 King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Submission01-Jul-2021
Date of Acceptance17-Aug-2021
Date of Web Publication30-Dec-2021

Correspondence Address:
Abeer Ayed Alshammari
Department of General Surgery, General Surgery Resident in NGHA, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_78_21

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  Abstract 


Paraduodenal hernia (PDH), also called mesocolic hernia, is a rare congenital anomaly. However, it accounts for up to 53% of all internal hernias, but they cause only 0.2%–0.9% of all cases of intestinal obstruction. Clinical findings are often indetermined. Computerized tomography is usually diagnostic; however, the diagnosis is often made intraoperative. PDH carries the risk of morbidity and mortality due to incarceration, leading to bowel obstruction and strangulation if not treated, that is why the patient should be repaired surgically not conservatively when the diagnosis is made. Here, we present a case of left-sided PDH with low-grade partial bowel obstruction, who underwent laparoscopic exploration and reduction of small bowel content that founded to be healthy and viable.

Keywords: Bowel obstruction, laparoscopic, paraduodenal hernia


How to cite this article:
Alshammari AA, AlYousef ZM, Alwahhabi FY. Paraduodenal hernia. Saudi Surg J 2020;8:202-4

How to cite this URL:
Alshammari AA, AlYousef ZM, Alwahhabi FY. Paraduodenal hernia. Saudi Surg J [serial online] 2020 [cited 2022 Jan 28];8:202-4. Available from: https://www.saudisurgj.org/text.asp?2020/8/4/202/334512




  Introduction Top


Internal hernia constitutes a protrusion of abdominal viscera or part of them through congenital or acquired orifices of the peritoneum of mesentery, within the peritoneal cavity.[1] Acquired orifices are mainly the result of surgical operation, frequently seen following some bariatric operations, especially Roux-en-Y gastric bypass, whereas other bariatric operations, such as the mini-gastric bypass, are devoid of internal hernia development.[1] On the other hand, congenital internal hernias are more common in a virgin abdomen and include paraduodenal (53%), paracecal (13%), foramen of Winslow (8%), transmesenteric (8%), intersigmoid, supravesical, and pelvic transomental hernias (1%–4%) [Table 1].[1] Paraduodenal hernias (PDHs), also called mesocolic hernias, rank first in frequency of appearance and are caused by malrotation of the mid-gut during the embryonic life, as well as by abnormal peritoneal fixation and vascular folds.[1] They represent a herniation of a segment or the entire small bowel into a peritoneal sac, derived from a fossa proximally to the fourth segment of the duodenum, with that fossa being inferior (60%), combined superior and inferior (30%), superior (5%) of the ligament of Treitz, the fossa of Landzert (2%), or the fossa of Waldeyer (1%), based on their clinical significant and highest incidence among congenital internal hernias.[1] Preoperative computerized tomography scan of the abdomen is usually diagnostic; however, the diagnosis is often made intraoperatively.[2] Surgical treatment can be performed with traditional open methods or minimally invasive laparoscopic techniques.[2] We describe herein the preoperative radiological diagnosis and successful laparoscopic repair of a left PDH in an adult man.[2] Here we are going to present a case of low grade bowel obstruction which was managed by laparoscopic surgical exploration, result in left sided PDH with healthy and viable small bowel content.
Table 1: Biochemical investigations

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  Case Presentation Top


In this case, we report a 20-year-old male patient who referred to the general surgery clinic, complaining of on/off defuse abdominal pain, lasting for few hours then relive; the pain is not related to food, no symptoms of bowel obstruction, and no fever nor urinary symptoms. Otherwise, he is medically and surgically healthy, with no significant medical history. On examination, he was vitally stable, abdomen is soft and lax, and investigations were all within normal ranges.

He underwent routine computed tomography (CT) scan of the abdomen and pelvis with intravenous and oral contrast [Figure 1].
Figure 1: Coronal view and axial of CT abdomen with IV and oral contrast showed presence of dilated loops and gastric balloon in the stomach

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CT showed clustered of small bowel loop at the left upper quadrant, suggestive of left PDH; some of the segments are dilated reaching 3.7 cm associated with minimal congested mesentry and left peritoneal reflection stranding; however, the oral contrast is passed to the colon suggestive of low-grade partial bowel obstruction. There is a 9.4 cm × 9.6 cm inflated gastric balloon. The liver, gallbladder, pancreas, spleen, adrenals, and urinary bladder are unremarkable. The kidneys show a 0.7 cm left renal angiomyolipoma at the lower pole. No lymphadenopathy was noted. Left paracolic gutter 0.7 cm peritoneal nodule nonspecific. Lung bases and osseous structures are unremarkable.

The impression

Features of left sided internal paraduodenal hernia with low grade partial bowel obstruction no malrotation.

After that, the patient was taken for laparoscopic exploration, after mobilization of the right colon, we found a left PDH with small bowel content, bowel was found healthy and viable, and it was reduced. Postoperative course was uncomplicated and uneventful. The patient has no abdominal pain since he left the hospital in day 2 postoperation.

After 1 month, the patient attended his follow-up in the clinic, he was doing fine, with no complaints, and CT requested for follow-up.

Findings showed

  • Gastric balloon is noted
  • Normal size, shape, and contour of the liver. No cystic or solid lesions. No dilated intrahepatic biliary radicles
  • Normal gallbladder, no radiodense gallstones. Normal extrahepatic bile ducts
  • Normal size, shape, and parenchymal density of the pancreas. No masses
  • Normal size, shape, and density of the spleen. No focal lesions
  • Normal size of both kidneys with normal parenchymal thickness. No renal stones or back pressure changes. No renal masses by noncontrast CT criteria
  • Normal both suprarenal glands. No masses
  • No ascites
  • Normal urinary bladder with uniform wall thickness and no evidence of stones or masses by noncontrast CT criteria
  • No pelvic masses or fluid collection
  • No abdominal or pelvic lymphadenopathy
  • Normal CT appearance of the prostate and seminal vesicles.


Summary of the CT findings

CT for follow-up showed

  • Gastric balloon is noted, otherwise normal CT study of the abdomen and pelvis
  • Normal size, shape, and contour of the liver. No cystic or solid lesions. No dilated intrahepatic biliary radicles
  • Normal gallbladder, no radiodense gallstones. Normal extrahepatic bile ducts
  • No significant abdominal wall hernia by CT criteria at time of examination.



  Discussion and Conclusion Top


PDHs, also known as mesocolic hernias, are congenital and derive from embryonary peritoneal anomalies and associated abnormal intestinal rotation.[3] These patients usually present with chronic abdominal pain and vomiting with or without signs of intestinal obstruction.[3] There is an associated risk of strangulation and intestinal infraction for more than 50% over the course of a lifetime, making it necessary to investigate radiological signs of hypoperfusion and intestinal ischemia.[3] The high rate of mortality associated with these complications makes early identification indispensable and justifies the role of abdominal CT in the early preoperative diagnosis of PDH.[4] Multislice CT offers high-resolution and multiplaner images, which may be very demonstrative and characteristic providing a precise and early diagnosis, useful for surgical treatment planning.[3] In typical CT images, PDH shows cluster of dilated bowel segment with engorged and displaced mesenteric vessels at the hernial orifice. Early surgical intervention is essential to avoid future complications[5] because patients with PDH have a 20%–50% mortality for acute presentation.[3] In 2019, there was a research for PDH in a systemic review of the literature; their study characteristics result was that a total of 115 studies were extracted for the present review.[1] All included studies were reports of a single case, except for 18 studies with a total of 62 patients, each reporting on a series of patients suffering from PDH.[1] Nearly all included studies reported specific data, regarding diagnosis, treatment strategy, and patient's outcomes.[1] They found by univariate logistic regression analysis that left PDH demonstrates a significantly higher perioperative morbidity rate, compared with right PDH, without any difference in the respective mortality rate.[1] Moreover, neither patient's age, gender. Nor a past medical history of an abdominal operation, were significantly correlated with the perioperative morbidity and mortality rates.[1] Regarding the symptoms and signs, the presence of pain was statistically significantly correlated with decreased mortality rate with patients with a PDH, without though influencing the morbidity rate. Bowel obstruction, due to the presence of a PDH, seemed to be associated with an increase morbidity rate, without though marginally establishing a statically significant correlation.[1] On the other hand, neither nausea and vomiting nor fever did influence the morbidity and mortality rates.[6] Surprisingly, the presence of a nonviable intestinal segment and the subsequent need for enterectomy were not correlated with an increased morbidity and mortality rate; equal findings were also observed for the radiological studies used to evaluate the source of abdominal pain.[1] The laparoscopic treatment of PDH demonstrates a significant decreased morbidity rate, compared with the respective open repair.[1] Laparoscopic repair was also associated with a significant decrease in length of stay in hospital, compared with open repair. Moreover, as it was expected an increased morbidity rate was strongly correlated with an increased length of stay.[1]

That is why we opted for laparoscopic approach for our case as it is confirmed by multiple cases that is better and less dangerous for the patient with PDH, and we did pre- and post-CT scan for our patient because the CT scan is still the gold standard modality. The limitation for our study is the number of the cases as it is one case.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schizas D, Apostolou K, Krivan S, Kanavidis P, Katsaros I, Vailas M, et al. Paraduodenal hernias: A systematic review of the literature. Hernia 2019;23:1187-97.  Back to cited text no. 1
    
2.
Laparoscopic Repair of a Right Para Duodenal Hernia. Read.qxmd.com. 2021. Available from: https://read.qxmd.com/read/20407574/laparoscopic-repair-of-a-right-para-duodenal-hernia. [Last accessed on 2021 Jun 13].  Back to cited text no. 2
    
3.
Para-Duodenal Hernia: A Report of Five Cases and Review of Literature. Read.qxmd.com. 2021. Available from: https://read.qxmd.com/read/29848337/para-duodenal-hernia-a-report-of-five-cases-and-review-of-literature. [Last accessed on 2021 Jun 13].  Back to cited text no. 3
    
4.
Trigui A, Guirat A, Rejab H, Kardoun N, Frikha F, Amar MB, et al. An uncommon cause of acute bowel obstruction: The left para-duodenal hernia. Niger J Surg 2012;18:97-9.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Hafeez Bhatti AB, Khan MA. Left paraduodenal hernia: A rare cause of large bowel obstruction and gangrene. J Coll Physicians Surg Pak 2012;22:250-1.  Back to cited text no. 5
    
6.
Armstrong O, Hamel A, Grignon B, Peltier J, Hamel O, Letessier E, et al. Internal hernias: Anatomical basis and clinical relevance. Surg Radiol Anat 2007;29:333-7.  Back to cited text no. 6
    


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