Author(s): Ahmad Essam Al-Mulla*, Maznah Al-Mutairi, Fawzia Ashkanani, Mohammed algazar, Mohammed Yousry abdelhamid and Nouf Al Alenezi
A para-duodenal hernia is a type of internal hernia, an atypical congenital anomaly. It presents as abdominal obstruction with adverse manifestations such as strangulation and infraction. Its symptoms can be ambiguous and variable, making them challenging to detect and diagnose. However, prompt intervention is required to avoid further complications. Here, we present the course and management of a 31-year-old male who contributed to our emergency department with symptoms of intestinal obstruction with an unusual C.T. scan and intra-operative findings
An internal hernia is classically defined as herniation of a viscus through a normal or abnormal opening within the peritoneal cavity [1]. Congenital internal hernias are uncommon, accounting for only 1% of all abdominal hernias [2-8]. Types of internal hernia are as follows para duodenal hernia (PDH), pericecal, Winslow foramen, transmesenteric, transmesocolic, pelvic, intersigmoid, retro anastomotic, and transmittal hernia [3].
Para-duodenal hernia is an unusual congenital abnormality presented as malrotation of the midgut. It is the most common type of internal hernia (53%), displaying left side dominance over the right side, with a ratio of three to one [2]. It is also three times more common in males than females [4]. PDH can occur at any age; however, it typically presents between the fourth and sixth decades of life with significant complications [5].
A 31-year-old male presented to our emergency department with a three-day history of diffused abdominal pain associated with constipation. Abdominal examination revealed generalized discomfort and tenderness in the paraumbilical and iliac fossa regions, with marked distention, sharp pain, absent bowel sounds, and empty rectum. The patient was admitted to the surgical ward for further investigation. Laboratory investigation found an elevated white blood count (WBC). A computer tomography (C.T.) scan of the abdomen and pelvis with intravenous and oral contrast revealed significant dilation of the small bowel crowded at the left upper quadrant region, with no thickening nor a definitive transitional zone. This pattern was suggestive of small bowel obstruction (Figure1). The patient was informed of the result and consented to surgery. The patient initially underwent diagnostic laparoscopy. However, it was converted to a midline incision due to narrowed space and obscure vision caused by dilated bowel loops.
Proximal jejunal loops were collapsed in the hernial sac (fossa of Landzert), causing an extraluminal compression effect on the splenic flexure with a backpressure effect at the transverse colon, right colon ileal loops and distal jejunal loops lead to close loop obstruction (Figure2). A band was dissected, and the inferior mesenteric vein was identified (Figure 3). The small bowel loops and hernia sac were pulled and examined, and the defect was identified and closed with sutures. No other pathology or ischemia was observed in the bowel.
The patient had an uneventful postoperative recovery period and was discharged after resuming a regular diet and bowel motion. The first outpatient visit was 14 days after discharge. He had no complaint, and his wounds were clean and dry with no signs of infection.
Para-duodenal hernia, also called congenital internal hernia or mesocolic hernia was initially described by Neubauer in 1786; Later, a further scientific description was provided by Treitz in 1857, who considered it a retroperitoneal protrusion of the abdominal viscera [6]. Jonnesco proposed an additional classification of right and left PDH in 1889 [7]. Left PDH is three times more prevalent than right PDH, presenting in 1-2 % of the population [8]. Left PDH is a congenital opening at the transverse mesocolon, causing retroperitoneal retro colic herniation of the proximal jejunum involving the (fossa of Landzert) as described in our case report. The right PDH, on the other hand, is a congenital disability leading to protrusion of the ascending mesocolon involving (the fossa of Waldyer) [9].
The rarity and vague abdominal symptoms of para-duodenal hernia make diagnosis challenging, potentially leading to adverse conditions if left unnoticed. Patients may be asymptomatic or complain of chronic abdominal pain with vomiting, leading to other diagnoses such as peptic ulcer disease, gastritis, biliary colic, diverticular disease, inflammatory bowel disease, and adhesive bowel obstruction [9]. The lifetime probability of incarceration and strangulation is 50% and 20-50% mortality, it is, therefore, crucial to identify and manage PDH in a patient [10].
The first pre-operative diagnosis of PDH was described in 1921 by Kummer by barium study imaging [11]. However, upper gastrointestinal studies were replaced by higher resolution C.T. scans that offer multiplanar images that can be demonstrative and precise. PDH in a C.T. scan can be observed as a smooth sac-like mass of small bowel between the stomach and the pancreas at the level of ligament Treitz with a stretching or mispositioning of mesenteric vessels [8].
Management of paraduodenal hernia follows the same principle as hernia surgery, reducing and resecting the hernia sac and resecting the necrotic bowel, if present, with the closure of the wide orifices to prevent future recurrence. Surgical approaches can be in the form of open and minimally invasive surgery. Only 28 cases were resolved laparoscopically between 1998 and November 2015 [12, 13]. In the case presented here, open surgery was performed due to dense adhesions and dilatated small bowel loops.
A paraduodenal hernia is an atypical differential diagnosis for small bowel obstruction. Nevertheless, it is essential to consider uncommon causes in patients with no prior surgical history, preventing adverse complications such as strangulation and bowel ischemia.
