Incidental paraduodenal hernia found during laparoscopic colectomy

Minimally invasive surgery for paraduodenal hernias: report of a case and mini-review of operative techniques

BACKGROUND

Paraduodenal hernias (PDHs) are the most common congenital internal hernias. Herein, we present a successful laparoscopic repair of a left PDH and we review the minimally invasive techniques that have been used to treat PDHs.

MATERIALS AND METHODS

An 18-year-old female patient with multiple visits to the emergency department for abdominal pain was ultimately diagnosed with a left PDH. She underwent a four-port laparoscopic repair. In order to review the minimally invasive PDH repair techniques used, we searched the PubMed® database and found 53 original studies with a total of 66 minimally invasive PDH repairs (51 left PDH repairs, 15 right PDH repairs) over a period of 24 years (1998-2022).

RESULTS

The patient's postoperative course was uneventful and she was discharged on the 7th postoperative day. The literature review showed that closure of the hernia orifice was performed in 88% of left PDH repairs, whereas wide opening of the hernia orifice with or without mobilization of the right colon was performed in 81% of right PDH repairs. Of the patients with available postoperative data, none experienced complications other than grade Ι according to the Clavien-Dindo classification in the early postoperative period, and only one patient presented symptomatic hernia recurrence at a median follow-up of 1 year.

CONCLUSIONS

Based on limited publications and our own experience, minimally invasive repair of PDHs has so far been shown to be feasible and safe in the great majority of cases without irreversible small intestine ischemia/peritonitis.

Right Paraduodenal Hernia as a Cause of Acute Abdominal Pain in the Emergency Department: A Case Report and Review of the Literature

Paraduodenal hernias (PDHs) represent an unusual cause of acute abdominal pain in the Emergency Department (ED) and are associated with high morbidity attributable to a challenging clinical and radiological diagnosis, as signs and symptoms mimic other frequent causes of acute abdominal pain. We report a right paraduodenal hernia in a 37-year-old female patient who presented to the ED complaining of abdominal pain located in the right lower abdomen and hypogastrium, accompanied by nausea. During diagnostic work up, the abdominal computed tomography scan revealed the presence of small bowel malrotation with concomitant right paraduodenal hernia. These findings were confirmed intraoperatively. We performed a brief literature review about the clinical manifestations and treatment options of right paraduodenal hernias, which retrieved only 30 articles related to this condition. Prompt diagnosis, radiological or intraoperative, of paraduodenal hernias is crucial because nearly 50% will progress to small bowel obstruction. Therefore, it is essential for every clinician to account for them in the differential diagnosis of acute abdominal pain in the ED.

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.

Left Paraduodenal Hernia: Case Report of Rare Cause of Recurrent Abdominal Pain

Internal hernia is a relatively uncommon condition and is a rare type of intestinal obstruction. Paraduodenal hernia is considered the most common type of internal hernias. The rare prevalence and the variable symptoms make the clinical diagnosis of paraduodenal hernia a diagnostic challenge. We present the case of a 26-year-old male patient presented with a seven-day history of generalized intermittent crampy abdominal pain accompanied by nausea and multiple episodes of vomiting. He was otherwise healthy and had no history of previous abdominal operations. Computed tomography scan of the abdomen demonstrated sac-like clustered small bowel loops noted in the left upper quadrant, in the anterior pararenal space, consistent with the diagnosis of left paraduodenal hernia. Laparoscopic surgery for the repair of the hernia was planned but it was converted to open surgery due to technical difficulties. The patient tolerated the procedure without complications, and he was asymptomatic in the follow-up visit. This case sheds light on the importance of considering the diagnosis of left paraduodenal hernia in patients with recurrent abdominal pain, particularly among those who have not undergone abdominal surgery previously.

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.

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 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.

Left paraduodenal hernia successfully treated with laparoscopic surgery: a case report

A 60-year-old Japanese man was referred for examination of abdominal pain. Abdominal MRI exactly demonstrated paraduodenal hernia. Propylthiouracil was administered until the patient became euthyroid, because Graves' disease was detected during the subsequent general examinations. Laparoscopic repair was then carried out. The sac collar, which had a diameter of about 30 mm, was located lateral to the ascending portion of the duodenum. Bowel incarcerated in the hernia sac was reduced and the hernia orifice closed. The postoperative course was good, and the patient was discharged 7 days after surgery. The diagnosis by MRI has made possible laparoscopic surgery for paraduodenal hernia.

Internal hernias: anatomical basis and clinical relevance

The aim of this study was to present and discuss the anatomical basis of internal hernias thanks to our clinical experience of 14 cases. Internal hernias are uncommon cases of acute intestinal obstruction when a viscera protrudes through an intraperitoneal orifice, remaining inside the peritoneal cavity. It excludes iatrogenic post surgical hernias. From an anatomical point of view, three kinds of orifices may be interested. The orifice may be normal: epiploic or omental (Winslow's) foramen, or abnormal through a pathologic transomental hole realizing an internal prolapsus or procidentia, without sac. Or this orifice may be a paranormal peritoneal fossa (para duodenal or retrocaecal) acting as a trap for the bowel: these hernias possess a sac and are considered as true hernias. The clinical diagnosis is always difficult. CT scan can be useful confirming the obstruction and leads to an urgent operation. This retrospective study evaluates diagnosis, management and follow-up according to the type of anatomical orifice and delay of surgery.