Left-Sided Paraduodenal Hernia: Report of a Case

Surg Today (2006) 36:651–654 DOI 10.1007/s00595-006-3205-x

Left-Sided Paraduodenal Hernia: Report of a Case Asım Cingi1, Pakize Demirkalem1, Manuk N. Manukyan1, Davut Tuney2, and Cumhur Yegen1 Departments of 1 General Surgery and 2 Radiology, Marmara University School of Medicine, Tophanelioglu cad. Altunizade, 34662 Istanbul, Turkey

Abstract Paraduodenal hernias are rare congenital malformations consisting of incomplete rotation of the midgut, which may lead to intestinal obstruction or simply be detected as an incidental finding at autopsy or laparotomy. We report a case of left paraduodenal hernia diagnosed preoperatively by computed tomography and operated on in an emergency setting for signs of peritoneal irritation. A misdiagnosis had been made when the patient suffered his first attack 6 months earlier and he had been treated for familial Mediterranean fever. We reduced the small bowel loops from the left paraduodenal hernia sac with ligation and transection of the inferior mesenteric vessels. The patient was discharged from hospital on postoperative day 4 after an uneventful recovery. Key words Paraduodenal hernia · Abdominal pain · Familial Mediterranean fever

Introduction Paraduodenal hernias, which result from incomplete rotation of the midgut, represent the major subclassification and account for 53% of all internal hernias.1 Right and left paraduodenal hernias are separate entities, differing in anatomic position and also in embryologic origin.2 They are characterized by abnormal fixation of the duodenum and jejunum. Clinically, most patients present with ill-defined episodes of abdominal pain, often progressing to partial or complete intestinal

Reprint requests to: A. Cingi Received: May 16, 2005 / Accepted: January 17, 2006

obstruction.1 Upper gastrointestional series with small intestine follow-through and abdominal computed tomography (CT) show anatomic relationships and provide time for early surgical management.3 Once a paraduodenal hernia is identified, operative treatment is inevitable because there is a 50% lifetime risk of obstruction.4

Case Report A 30-year-old man was admitted to the emergency department of Marmara University Hospital for investigation and treatment of epigastric and intermittent colicky left-sided abdominal pain followed by episodes of nausea and vomiting. Blood analysis, urine analysis, and a plain abdominal radiograph showed no abnormalities, except for leukocytosis of 13 600/ml. On physical examination, the abdomen was tense and rigid with left-sided predominance. He had no history of abdominal surgery. He reported having experienced similar episodes several times in the last 6 months, but the pain resolved spontaneously each time. He was admitted to our emergency department 5 months earlier, but abdominal ultasonography did not demonstrate any abnormality. His pain was initially thought to have been caused by familial Mediterranean fever (FMF). He was prescribed colchicine 0.5 mg twice daily, but he discontinued the medication after 4 months because his symptoms did not improve. On the present admission, his fibrinogen level was normal (2.33 mg/dl) and abdominal ultrasonography showed no abnormality. However, abdominal CT showed a cluster of small-bowel loops encased in a sac in the left upper abdomen, in close proximity to the pancreas, displacing the stomach to the right. There was mesenteric swelling of the entrapped intestinal segment as well as suspected ischemic changes (Fig. 1). Following radiologic evaluation, we diagnosed an internal

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Fig. 1. Computed tomography scan of the upper abdomen, showing small-bowel loops within a sac-like structure. The black arrow points to the mesenteric swelling

A. Cingi et al.: Paraduodenal Hernia

herniation and performed an emergency laparotomy, which revealed that about one third of the proximal small intestine was encapsulated in a peritoneal sac. This sac was surrounded by transverse-descending mesocolon, entering the Landzert fossa through an opening just under the inferior mesenteric vessels (Fig. 2a). The bowel was easily reduced from the sac manually and there were no ischemic changes (Fig. 2b). The inferior mesenteric vessels formed the anterior wall of the defect. The intestinal loops were entrapped through the defect because of their anamolous fixation point behind the vessels, which were then clamped. Since there was no ischemic change in the descending and sigmoid colon, they were divided and ligated with 2-0 silk sutures. After wide excision of the peritoneal sac, the abdomen was closed in a single layer with a No. 1 PDSLoop suture (Fig. 2c). The patient had active bowel sounds on postoperative day (POD) 1 and resumed oral intake POD 2. He was discharged on POD 4 and has been well since.

a

c

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Fig. 2a–c. Operative view. a A cluster of small bowel loops encapsulated in a peritoneal sac. b The bowel loops were reduced easily from the sac manually. c The peritoneal sac was divided gently

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Fig. 3. Schematic diagram of the anatomical findings of the left paraduodenal hernia. IMA, inferior mesenteric artery; IMV, inferior mesenteric vein

Discussion Paraduodenal hernia is an unusual cause of intestinal obstruction.2 A remarkable feature of this type of internal hernia is that it may remain asymptomatic during the lifetime of a person and be reported as an autopsy finding.3 The clinical symptoms of an internal hernia may be intermittent and nonspecific with gastrointestinal manifestations such as abdominal pain, nausea, and vomiting. A correct diagnosis might not be made on the first admission to hospital, as in our patient.5,6 We learned from the hospital reports that our patient had also been evaluated with CT during his first admission. Although the laboratory findings were inconclusive, his clinical picture was thought to be consistent with FMF and he was prescribed ineffective treatment with colchicine. As a large proportion of patients with FMF in the world live in Turkey,7 some nonspecific abdominal complaints without definitive diagnosis are attributed to this disease. Even acute pancreatitis is sometimes misinterpreted as FMF,8 and this incorrect diagnosis and delay in the diagnosis and treatment might result in catastrophic consequences.2,6 According to Meyers, a correct preoperative diagnosis could be made only by upper gastrointestinal series with small intestine flow-through and angiography.9 Abdominal CT is currently used in the diagnosis of

paraduodenal hernia and has a high diagnostic accuracy in defining the possible etiology. The CT criteria for the diagnosis of paraduodenal hernia were described as a clustering of small-bowel loops, a sac-like mass with encapsulation at or above the ligament of Treitz, a mass on the posterior stomach wall, mesenteric vessel abnormalities, and depression of the transverse colon.10 Blachar et al. reported that by using these criteria, paraduodenal hernias could be diagnosed with the highest degree of confidence.11 In addition to CT findings, diagnostic laparoscopy may confirm the diagnosis.12 We based our preoperative diagnosis on the CT findings which, in accordance with established criteria, featured clustering of dilated small bowel loops as an encapsulated mass on the left side with displacement of the stomach. Possible ischemic changes were also indicated by the CT findings. During the surgical exploration, all these findings were confirmed, but the ischemic appearance was reversed after liberation of the incarcerated intestinal loops and the application of hot compresses over the affected loops. The essential steps in surgical treatment include bowel reduction and obliteration of the hernia defect by simple closure or incision of the sac in the avascular plane, by open or laparoscopic surgery.2,12,13 In our patient, we reduced the sac contents and assessed the viability of the intestinal segment. The retroperitoneal

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fixation of the reduced segment led to immediate replacement of the intestinal contents into the hernia sac. The edematous mesocolon and hernia orifice precluded safe closure of the defect, so we considered it necessary to divide the inferior mesenteric vein for definitive repair. Although this is not a recommended maneuver,2 Bartlett et al.14 reported that division of the inferior mesenteric vein could be performed without compromising the intestines. High tie of the inferior mesenteric artery in distal colorectal resections has also been shown to be a safe procedure.15 Our patient had an uneventful recovery. The clinical findings in some patients with a paraduodenal hernia may be nonspecific and even misleading. Radiological guidance, especially by CT, should be carried out with a high index of suspicion to prevent misdiagnosis and delay in surgical intervention, which may result in irreversible ischemic changes of the small bowel. A correct preoperative diagnosis may also help surgical planning in patients with altered anatomy, and assist in the differential diagnosis of other defined rare internal hernias.16 Although attention should be paid to preserving the vessels forming the anterior wall of the hernia sac, they can be sacrificed if a safe repair is not possible without division of the inferior mesenteric vein.

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