Hellenic Journal of Surgery 86

An Interesting Case of a Left Paraduodenal Hernia with Peritoneal Encapsulation Presenting as Acute Intestinal ObstructionArghya Basu, Amit Kumar Gupta, Soumika Biswas, Manas Kumar Dutta

Hellenic Journal of Surgery (2014) 86:2, 109-111

Arghya Basu, Amit Kumar Gupta, Manas Kumar DuttaDepartment of General Surgery, Medical College KolkataSoumika BiswasDepartment of Biochemistry, Medical College Kolkata

Corresponding author: Dr. A. Basu26A, Keshab Chandra Sen Street, West Bengal, India Postal Code: 700009, Tel.: +91 9051202232, +91 9477116161 E-mail: dr.arghyarox@gmail.com, dr_arghya_basu85@yahoo.co.in

Received 16 Oct 2013; Accepted 13 Feb 2014

CASE REPORT

Abstract

Internal hernias commonly present as left duodenal, right duodenal, mesocolic, or retrocolic, intersigmoid hernias, as well as herniation through the foramen of Winslow and lesser sac herniation through an abnormal orifice [1]. Paraduodenal hernias are extremely rare entities, which may prove dangerous because of the high risk of bowel obstruction, strangulation and gangrene. These hernias are notorious because of non-specific signs and symptoms that can lead to diagnostic difficulties. We report the case of a left paraduodenal hernia with peritoneal encapsulation presenting as acute intestinal obstruction in a patient without any history of prior abdominal surgery. The patient underwent bowel reduction, adhesiolysis, resection of the sac, and repair of the defect. The patient’s recovery was uneventful.

Keys words: Paraduodenal hernia, intestinal obstruction, peritoneal encapsulation, malrotation

A 21-year-old Indian female was admitted with acute abdominal pain, fever, abdominal distension, constipation and two days of bilious vomiting. The patient had no his-tory of abdominal surgery or injury, but over the past three years, she had occasionally experienced recurrent abdomi-nal pain which subsided with medication. She was febrile with marked dehydration, tachycardia and tachypnoea. On examination, the abdomen was distended, diffusely tender with rebound tenderness and loud bowel sounds. Shifting dullness or fluid thrill could not be elicited.

Haematological investigations revealed leucocytosis with neutrophilia. A plain abdominal X-ray revealed mul-

Introduction

Paraduodenal hernias are rare anomalies of the midgut caused by malrotation of the gut in peritoneal spaces and folds near the ligament of Treitz [1,2]. Left paraduodenal hernias are most commonly found in relation to the fossa of Landzert and are caused by plica venosa, a peritoneal fold wrapped around the inferior mesenteric vein. They may present with intermittent and non-specific clinical features like acute or chronic abdominal pain, or they may remain asymptomatic for a lifetime. Symptomatic cases with complications are reported to have high mortality and mor-bidity. Hence, timely diagnosis is of utmost importance to prevent complications such as bowel obstruction, ischaemia, strangulation, gangrene, and rupture. We report the case of a left paraduodenal hernia with peritoneal encapsulation presenting as intestinal obstruction in a patient without any history of prior abdominal surgery.

Case Report

Written informed consent was obtained from the patient.

Figure 1. Hernial sac containing strangulated small bowel

110 Arghya Basu et al

Hellenic Journal of Surgery 86

tiple air fluid levels and vulvulae conniventes. Abdominal ultrasonography identified a distended gall bladder with sludge and microcalculi and dilated fluid-filled bowel loops without ascites.

Exploratory laparotomy was performed through a stand-ard midline incision. A large left paraduodenal hernial sac was found which almost enclosed the entire small gut from the duodenal-jejunal junction to the ileocaecal junction. The content of the sac entered through an opening just below the fourth part of the duodenum. The contained part of the gut was filled with fluid; it was distended, and severely congested, but returned to its normal colour after administration of 100% oxygen and warm mop. The inferior mesenteric vein was found to pass anterior to the terminal ileum. Redundant sigmoid colon with a long mesenteric at-tachment was found which was not related to an obstruction.

Figure 2. Gut inside hernial sac Figure 3. Sac containing gut

Figure 4. Sac wall being spread out Figure 5. Sac wall being excised

The gut content was reduced, and the hernial sac excised near and along its attachment. An appendicectomy was also performed as the appendix was raw and severely inflamed. A thorough lavage was carried out, and haemostasis was established. The abdomen was closed in layers after drain placement in the hepato-renal pouch and pelvis. The drains were removed four days after surgery, and skin sutures were removed 10 days post surgery. Histopathological examina-tion of the sac wall revealed normal peritoneal tissue. The patient had an uneventful recovery. During seven years of follow-up, no complications were reported.

Discussion

With an incidence rate of 1-2%, internal hernias are a rare congenital or acquired entity (traumatic, postoperative,

Paraduodenal Hernia Presenting as Intestinal Obstruction 111

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Figure 6. Inferior mesenteric vein passing in front of the ileum

postinflammatory, idiopathic) originating from a defect in the lesser omentum, greater omentum, mesentery, transverse mesocolon or sigmoid mesocolon [3]. They carry a high risk of ischaemia, gangrene, strangulation and possible perforation. Internal hernias are commonly paraduodenal hernias and mostly left-sided, but they can also present as mesocolic, supravesical, intersigmoid, omental, and ileocae-cal hernias, as well as herniation through the foramen of Winslow or abnormal orifices [4].

In most reported cases, the vasculature arises from the superior mesenteric vessels converging at a level cephalad to the gastric lower body; however, in this case the concerned vasculature originated from the inferior mesenteric vessels which passed in front of the terminal ileum.

The herniated bowel remains clustered and reversed within a peritoneal capsule, leading to compression, crowd-ing, displacement and obstruction of both the bowel and blood vessels [5]. Since such complications are inconsistent and intermittent, these hernias are very difficult to diagnose clinically or radiographically. Conventional plain abdominal radiography, computed tomography (CT), barium studies, and even an angiogram have been used to identify a peri-toneal capsule in cases of an internal hernia; CT scanning is the gold standard with >75 % sensitivity [6].

In the case of a paraduodenal hernia, the gut is gener-

ally encapsulated in an accessory peritoneal membrane which originates from the peritoneal yolk sac; hence, left paraduodenal hernias are generally referred to as congenital mesocolic hernias. Such hernias are believed to be the result of a reversed rotation of the midgut into the mesocolon, or herniation of midgut loops through a congenital or patho-logical defect between posterior parieties and the inferior mesenteric vein [7].

Persistent or intermittent internal herniations, if not diagnosed properly and in time, present a risk of ischae-mia, gangrene, or possible perforation, which could have a lethal outcome [8]. Perioperative misdiagnosis has often been reported in the literature. Consequently, thorough knowledge and heightened suspicion along with immediate surgical intervention are essential to reduce morbidity and mortality in such patients.

Conflict of interest

All authors declare that they have no competing interests.

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