Combined transmesocolic and left paraduodenal hernia: barium, CT and MRI features

Rare cause of chronic abdominal pain: left paraduodenal hernia and its surgical management

A 30-year-old man presented with colicky abdominal pain for 2 months, associated with occasional episodes of bilious vomiting. He had a history of similar complaints at the age of 16 and 26 years. Contrast-enhanced computed tomography abdomen was consistent with a diagnosis of left paraduodenal hernia. On laparoscopy a 3 × 3 cm hernial defect was identified in the left paraduodenal fossa (fossa of Landzert). Contents were jejunal, and proximal ileal loops which were dilated and edematous. Anterior border of the sac was formed by the inferior mesenteric vein and left branch of the left colic artery. Initial reduction of contents was easy. However, complete reduction proved to be difficult due to adhesions with the sac opening, the hernial sac instead laid open by dividing the Inferior Mesentric Vein (IMV) (anterior border of defect) using a vascular stapler. The patient was discharged on postoperative day 3 in a stable condition. On follow-up the patient is doing well.

Treitz Hernia: Report of a Case and Review of the Literature

INTRODUCTION

Congenital hernias are rare findings, and their diagnosis is often delayed due to an incorrect interpretation of the clinical symptoms and/or images. We present a rare case of left-sided paraduodenal hernia at the ligament of Treitz, followed by a review of the literature.

CASE PRESENTATION

We report the case of a 20-year-old patient with unusual, recurring abdominal pain in the past 3 months. There were no previous operations or past illnesses in the patient's history. The computed tomographic scan showed a misplacement of small bowel into the lesser sack. With high suspicion of an internal hernia, we performed a diagnostic laparoscopy, which revealed a Treitz hernia. The reduction and fixation could be carried out fully with minimally invasive surgery with an uneventful postoperative course and complete recovery.

CONCLUSION

A Treitz hernia is a rare cause of unspecific abdominal pain and the clinical signs are difficult to interpret. However, its knowledge may help to avoid emergency procedures and provide quick recovery of the patients. We recommend the laparoscopic approach as the first choice of treatment in all cases of internal hernia in the absence of peritoneal irritation or severe bowel obstruction.

A causal relationship between right paraduodenal hernia and superior mesenteric artery syndrome: a case report

Introduction

Cases of right paraduodenal hernia and superior mesenteric artery syndrome have been reported separately, but their occurrence in combination has not been reported.

Case presentation

A 46-year-old Japanese man who had never undergone laparotomy was admitted to our hospital due to an acute abdomen. An enhanced multidetector-row computed tomography scan of our patient showed a cluster of small intestines with ischemic change in his right lateral abdominal cavity. Emergency surgery was subsequently performed, and strangulation of the distal jejunum along with incidental right paraduodenal hernia was found. His necrotic ileum was resected, and the jejunum encapsulated by the sac was repaired manually without reduction.

Three days after the operation, however, our patient developed vomiting. An upper gastrointestinal series revealed a straight line cut-off sign on the third portion of his duodenum. A second enhanced multidetector-row computed tomography scan showed that he had a lower aortomesenteric angle and a shorter aortomesenteric distance compared to his condition before his right paraduodenal hernia was surgically repaired. We strongly suspected that the right paraduodenal hernia repair may have induced superior mesenteric artery syndrome. On the 21st post-operative day, duodenojejunostomy was performed because conservative management had failed.

Conclusions

In this case, enhanced multidetector-row computed tomography, which permits reconstructed multiplanar imaging, helped us to visually identify these diseases easily. It is important to recognize that surgical repair of a right paraduodenal hernia may cause superior mesenteric artery syndrome.