Anterior and upward displacement of the inferior mesenteric vein:a new diagnostic clue to left paraduodenal hernias?

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.

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.

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.

Acute intestinal obstruction secondary to left paraduodenal hernia: a case report and literature review

Introduction

An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Although they are considered as a rare cause of intestinal obstruction, paraduodenal hernias are the most common type of congenital hernias.

Methods

A literature search using PubMed was performed to identify all published cases of left paraduodenal hernia (LPDH).

Results

In Literature search between 1980 and 2012 using PubMed revealed only 44 case reports before the present one. Median age was 47 years (range 18 – 82 years). Nearly 50% reported previous mild symptoms. Two-third of patients required emergency surgery in form of laparotomy or laparoscopic repair. Reduction of hernia contents with widening or suture repair of the hernia orifice were the most common standards in surgical management of LPDH.

Conclusion

Intestinal obstruction secondary to internal hernias is a rare presentation. High index of suspicion and preoperative imaging are essential to make an early diagnosis in order to improve outcome.

Transmesocolic hernia of the ascending colon with intestinal obstruction

An internal hernia may be either congenital or acquired. The reported incidence of such hernias is 1–2%. In rare cases, internal hernias are the cause of small bowel obstruction, with a reported incidence of 0.2–0.9%. Transmesocolic hernia of the ascending colon is especially rare. We report a case of transmesocolic hernia of the ascending colon with intestinal obstruction diagnosed preoperatively. A 91-year-old Japanese female was admitted to our hospital with abdominal distention and vomiting of 3 days duration. She had no past history of any abdominal surgery. Abdominal examination revealed distention and tenderness in the right iliac fossa. Abdominal computed tomography revealed ileus in the sac at the left side of the ascending colon and dilatation of the oral side of the intestine. We diagnosed a transmesocolic hernia of the ascending colon with intestinal obstruction and performed emergency surgery. At the time of operation, there was internal herniation of ileal loops through a defect in the ascending mesocolon, without any strangulation of the small bowel. The contents were reduced and the tear in the ascending mesocolon was closed. The postoperative course was uneventful and the patient was discharged 14 days after surgery. In conclusion, preoperative diagnosis of bowel obstruction caused by a congenital mesocolic hernia remains difficult despite the techniques currently available, so it is important to consider the possibility of a transmesocolic hernia when diagnosing a patient with ileus with no past history of abdominal surgery.

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.

Sonographic features of internal hernia

OBJECTIVE

The purpose of this series is to describe the sonographic findings in 4 patients with intestinal obstruction due to internal hernia.

METHODS

Four patients had clinical features of intestinal obstruction. Sonography was performed with broadband convex and linear array transducers in these patients.

RESULTS

In all 4 patients, there were features of intestinal obstruction with a zone of transition between dilated and nondilated bowel. There was a cluster of crowded, compressed, and aperistaltic small-bowel loops, as if they were tightly packed within a sac, by the side of this zone in 3 patients. This appearance was due to obstruction of the afferent loop caused by compression. In the last patient, there were 2 loops of dilated bowel within a sac outlined by fluid due to obstruction of the efferent loop. All 4 patients had obstructed internal hernias at laparotomy.

CONCLUSIONS

Sonographic features of internal hernia are described.

Transient left paraduodenal hernia

A 52-year-old woman with acute deterioration of recurrent abdominal pain was admitted to the hospital. Spiral computed tomography (CT) of abdomen was performed. A left paraduodenal hernia was identified on CT. There was no clinical sign or imaging finding suggesting intestinal obstruction or mesenteric ischemia. She refused surgical intervention since her pain was intermittant and decreasing. On the fifth day of hospitalization the patient's pain resolved completely and the follow-up CT demonstrated regression of the herniation.

Internal hernia with volvulus and intussusception: case report

An 82-year-old male presented to the hospital because of acute exacerbation of abdominal pain and biliary vomiting. Contrast-enhanced computed tomography of the abdomen was performed. A left paraduodenal hernia associated with volvulus, intussusception, and bowel wall ischemia were radiologically diagnosed. Surgery confirmed the diagnostic imaging findings. We present the first case of an association of these acute abdominal conditions.