Hussain, S

Munir, A

Saleem, S M

English

eCommons@AKU

eCommons@AKUSection of Paediatric Surgery Department of SurgeryMarch 2004Paraduodenal hernia--a case reportA MunirAga Khan UniversityS M. SaleemS HussainFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_paediatrPart of the Pediatrics Commons, and the Surgery CommonsRecommended CitationMunir, A., Saleem, S. M., Hussain, S. (2004). Paraduodenal hernia--a case report. Journal of Pakistan Medical Association, 54(3),162-163.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_paediatr/31IntroductionInternal hernias, herniation of a segment of intestineinto an intraperitoneal fossa, are uncommon causes ofintestinal obstruction and are difficult to diagnose pre-operatively. 1 We report a case of one and a half year oldmale infant presenting with para-duodenal internalherniation of small bowel.Case ReportWe report a case of a one-year-old boy whopresented to the emergency room with 36-hour history ofabdominal pain and vomiting, progressing from non-biliousto bilious and ultimately faeculent.  There was also historyof constipation and abdominal distension.  Prior to thisepisode, the child was well with no co-morbid conditions.Examination revealed a listless, tachycardic anddehydrated infant with distended abdomen, which was tenseand tender.  The plain abdominal X-ray was consistent withintestinal obstruction (Figure 1).  The provisional diagnosisof intussusception was made.  After initial resuscitation acontrast enema was done, which showed downwarddisplacement of transverse colon with distended smallbowel loops (Figure 2). There was partial hold-up ofcontrast in mid-transverse colon (Figure 3). Exploratorylaprotomy for mechanical bowel obstruction was planned.On exploration there was serosanginous peritoneal fluid,Paraduodenal Hernia -  a Case ReportA. Munir, S. M. Saleem, S. HussainSection of Pediatric Surgery, Department of Surgery, The Aga Khan University, Karachi.Vol. 54, No. 3, March 2004 162with stretched out collapsed transverse colon.  Small bowelwas seen herniating through the mesentery of transversecolon, which was stretched on it (Figure 3).  After reductionof small bowel, the defect was identified to be in leftparaduodenal space.  Bowel was reduced which wascongested but viable and than the defect was repaired withvicryl, taking care of the vessels at the mouth of the defect .DiscussionInternal hernias are uncommon and rarely diagnosedpre-operatively.  Internal abdominal hernias are defined asthe herniation of a viscus through an intraperitoneal orificeor aperture within the confines of the peritoneal cavity.1Incidence has been variably reported to be 1- 2%.1-3The hernias may be discovered as incidental findingsat the time of laprotomy or autopsy, or they may give rise tochronic dyspeptic symptoms.  It may present as complicationin the form of bowel obstruction, strangulation orperforation.  Internal hernia is an un-common cause of bowelobstruction with a reported incidence of 0.2-0.9%.2The orifice of the internal hernia may be normal(Winslow's foramen) or abnormal (Para-duodenal, Ileocecaletc) or pathological (orifice formed in a mesentery oromentum) or  anomalis orifice.4More than 50% of internal hernias reported in theliterature have been paraduodenal.2 Seventy-five percent ofpara-duodenal hernias occur on the left, while 25% occur onthe right.2,3,5,6 They originate at the fossa of Landzert whichis just lateral to the fourth segment of the duodenum andbehind the IMV and ascending left colic artery. 5,7 Rightparaduodenal hernias protrude into the ascendingmesocolon, involving the fossa of Waldeyer, behind theSMA and inferior to the third portion of the duodenum.6 The paraduodenal hernias are more common inmales (M:F ratio 3:1).5 The average age at diagnosis is 38.5years with clinical presentation often due to chronic,intermittent, postparandial abdominal pain.5 An accurateincidence of paraduodenal hernias in infancy and childhoodis unknown, but quite rare.Left paraduodenal hernias are a rare cause ofabdominal pain or obstruction. However, because there ishigh associated mortality (20%)3,8, prompt and accuratediagnosis is essential, which determines the clinicaloutcome. Because internal hernias are not detectable onphysical examination, imaging is relied upon for pre-operative diagnosis.7,9 Since, herniation is oftenintermittent, the radiographic diagnosis therefore dependson the time of imaging.  Plain film radiographic findings areusually nonspecific (normal, partial or complete bowelobstruction); yet, UGI-small bowel follow-through, CTscan and occasionally ultrasound (the latter not in our case)may make the diagnosis by identifying isolated bowel, "abag of bowel", in the hernia sac.9 Radiographically, left paraduodenal hernias presentas an ovoid conglomeration of jejunal loops in the left upperquadrant, often displacing the stomach superiorly and thetransverse colon inferiorly.2,3 Right paraduodenal herniasare similarly ovoid but are located on the right, displacingthe ascending colon anterolaterally.  Barium studies andCT examination of these hernias may also show the point oftransition where the bowel loops enter or exit the orifice.Angiography reveals an altered course of the jejunal vesselsas they course along the herniated portion of bowel.2 Treatment is based on reduction of the hernia andclosure of the defect with care not to injure the vessels nearthe hernial sac margin.6 With internal hernias, the bestcourse is to correct the defects in the mesentery and theabnormalities of malrotation when incidentally noted. Rightmesocolic herniation is repaired by moving the colon to theleft after dividing the peritoneal attachments and leaving thesmall bowel on the right. Left mesocolic herniation istreated by making an incision where the encapsulated herniasac fuses with the left mesocolon to release the trappedbowel.3References1. Takashi Y, Yasuo Y, Yasusuke M. Emergency abdominal surgery for sigmoidmesocolic hernia. Am J Emerg Med 2002;20:137-8.2. Blachar A, Federle MP, Dodson SF,  et al. Internal hernia: clinical andimaging findings in 17 patients with emphasis on CT criteria. Radiology2001;218:68-74.3. William H, Rohan J. Abdominal hernias and their complications, includinggastric volvulus. In: Sleisenger and Fordtran's gastrointestinal and liverdisease, 7th ed. Philadelphia: W. B. Saunders, 2002, pp. 381-2.  4. Gullino D, Giordano O, Gullino E. Internal hernias of the abdomen: a proposof 14 cases. J Chir (Paris) 1993;130:260-4.5. Anthony T. Aunt Minnie's Corner. J Comp Asst. Tomog 1998; 22:844.6. Eric R, Oscar R, Mitchel K. Paraduodenal hernia: a report of two cases. AmSurg 2001;67:733-6.7. Bartlett M, Wang C, William H. The surgical management of paraduodenalhernias. Ann Surg 1968;168:249-54.8. Yves J, Alex S, Lesile W. Mesenteric hernia. Surg. Gynecol Obstet1980;150:747-52.9. Donnelly F. Left paraduodenal hernia leading to ileal obstruction. PediatrRadiol 1996;26:534-6.J Pak Med Assoc163

Paraduodenal hernia: A case report

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Paraduodenal hernia: A case report

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