Small bowel obstruction secondary to left paraduodenal hernia: A case report and literature review

Left paraduodenal hernia: a rare cause of gastric outlet obstruction and large bowel obstruction

Paraduodenal hernia is a rare subset of internal hernia and an uncommon aetiology of bowel obstruction. A 50-year-old male presented with a 12 h history of severe epigastric pain and vomiting. A contrast enhanced computed tomography scan of the abdomen and pelvis demonstrated gastric outlet obstruction and large bowel obstruction due to left paraduodenal hernia involving the distal transverse colon and gastric antrum. After resuscitation, a laparotomy was performed, the bowel was reduced, the mesocolic defect repaired, and small bowel mesentery widened. The large bowel was decompressed via the appendix stump. The post-operative recovery was unremarkable. Left paraduodenal hernia is a rare condition and where seen acutely, usually presents with small bowel obstruction. Here the patient presented with a large bowel obstruction, a rare presentation of this uncommon condition. Operative intervention is mandatory in the acute setting to prevent ischaemia and perforation from strangulation of the bowel.

Robotic repair of a right paraduodenal hernia: a clinical presentation and management

Paraduodenal hernias are rare internal hernias in which the small intestine becomes trapped behind the mesentery of the colon. These hernias can lead to bowel obstruction and ischaemia, making early diagnosis and intervention crucial. Patients often exhibit non-specific symptoms, highlighting the importance of using CT imaging for diagnosis. Prompt surgical correction is necessary to prevent severe complications such as bowel ischaemia or necrosis. While open and laparoscopic approaches are well-established, there is limited evidence on the robotic repair of paraduodenal hernias as a minimally invasive technique. This case report describes a man in his early 30s who presented with persistent abdominal pain and vomiting. Imaging revealed a right paraduodenal hernia with characteristic CT findings showing clustered jejunal loops and abnormal mesenteric rotation. The patient successfully underwent robotic hernia repair, which involved identifying and reducing the hernia sac and securing the defect with polypropylene sutures. The postoperative recovery was complication-free. This case underscores the effectiveness of robotic techniques in managing this rare presentation and emphasises the importance of timely diagnosis and intervention.

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.

A late presentation of a left paraduodenal hernia in an elderly patient admitted in emergency: A case report

Small bowel internal hernias (IHs), a rare cause of small bowel occlusion (SBO) and small bowel strangulation, while more commonly seen in young adults, can also affect elderly patients and pose a significant diagnostic challenge due to their nonspecific symptoms. In most cases, laparotomy was used to diagnose IHs. However, multidetector computed tomography (MDCT) is usually the best imaging tool to use in the emergency setting for the diagnosis of IHs. An 83-year-old man was admitted to emergency with acute abdominal pain and a coffee-ground vomitus. The abdominal MDCT showed a clustered-like appearance of proximal jejunal loops at the level of the Treitz ligament with the absence of transit of the medium water-soluble iodine oral contrast agent (Gastrografin). Mesenteric edema was also present with initial suffering of the intestinal wall. A left paraduodenal hernia (LPDH) with strangulation was suspected following the radiological report. The emergency laparotomy revealed about 20 cm of proximal jejunal loops herniated through a 3 cm wide hernia orifice (HO) along the Treitz ligament, at the level of Landzert fossa, located in the confluence of the descending mesocolon, posterior to the inferior mesenteric vein (IMV) and confirming the LPDH. The patient was discharged in good condition some days later. IHs do not have sufficient coverage in literature, especially in cases regarding elderly patients, however, they can be a cause of SBO in people older than 80 years of age. Radiologists and surgeons should be aware of the anatomical aspects of the IHs.

Congenital Dual Internal Hernias Causing Small Bowel Obstruction in a Man with no Prior Surgical History: A Report of a Very Rare Case

Patient: Male, 51-year-old

Final Diagnosis: Congenial dual internal hernia with small bowel obstruction

Symptoms: Abdominal pain • vomiting • constipation

Medication: —

Clinical Procedure: —

Specialty: Surgery

Identification and Repair of Left-Sided Paraduodenal Hernia Using Both Laparoscopic and Robotic Techniques

Internal hernias are an uncommon cause of small bowel obstruction and present a challenging clinical diagnostic scenario. They result from the abnormal protrusion of an abdominal organ through a peritoneal defect and can cause intermittent obstructive symptoms, diffuse abdominal discomfort, and postprandial pain. Paraduodenal hernias comprise 53% of all internal hernias ¹ and occur due to failure of the fixation of either the left or transverse mesocolon to the posterior abdominal wall. Its relative rarity results in mortality between 20 and 50% ² because of delayed diagnosis and consequent obstruction, strangulation, and bowel ischemia. Our case series describes three patients before and after operative fixation of paraduodenal hernia. Only one of the three was identified by preoperative radiologist interpretation. Subsequent diagnosis and definitive treatment were completed by surgical staff to resolve undiagnosed undulating abdominal pain and obstructive-type symptoms. We further analyze left-sided paraduodenal hernias after laparoscopic and robotic repair to define common symptomatology, typical CT findings, and preferred laparoscopic repair techniques.

Closed loop small bowel obstruction due to paracaecal internal herniation: a lesson in rarity

A 40-year-old man presented to the emergency department of our tertiary hospital with acute abdominal pain since 1 day, which responded to conservative measures initially. On further investigation and abdominal CT, he was diagnosed with closed loop small bowel obstruction with an encapsulated lesion with small bowel loops within, in the right iliac fossa, which was initially missed. On exploration, the patient had a sac in the right iliac fossa (paracaecal incarcerated internal hernia) with distended bowel loops within, the sac was excised after reduction of the contents. Postoperative recovery was uneventful.