Laparoscopic repair of acute small bowel obstruction due to left paraduodenal hernia: A case report.

INTRODUCTION: Paraduodenal hernia is a rare disease but the most common internal hernia. Laparoscopic repair of paraduodenal hernia is feasible and effective because of its minimal invasiveness and aesthetic advantage. PRESENTATION OF CASE: We report a case of a 79 year-old-man who was admitted with a complaint of recurrent left abdominal pain. Computed tomography revealed an encapsulated cluster of jejunum loops in the left upper quadrant, near the ligament of Treitz and at the dorsal side of the inferior mesenteric vein. Emergency laparoscopic surgery was performed. The jejunum loops incarcerated in the hernia sac was reduced. The hernia orifice was closed with interrupted suture. Postoperative period was uneventful and the patient was discharged home on the 7th postoperative day. There has been no recurrence during a follow-up. DISCUSSION: If there is a working space in the abdominal cavity, laparoscopic surgery for paraduodenal hernia leads to patient's early recovery with cosmetic satisfaction.
CONCLUSION: Left paraduodenal hernia is a rare cause of small bowel obstruction that should be thought about patient with a history of recurrent abdominal pain. Computed tomography is the standard for a correct diagnosis. Laparoscopic repair as the first surgical option for paraduodenal hernia is feasible despite of technical difficulties.

Introduction

Paraduodenal hernia is an internal hernia which form the peritoneal cavity near the ligament of Treitz. It sometimes causes strangulated ileus with small bowel obstruction, which is the most common of all internal hernias. Recently, the cases of laparoscopic repair for paraduodenal hernia are reported with advantages in minimally invasive surgery. Herein, we describe the case of a patient who was preoperatively diagnosed with left paraduodenal hernia and underwent successful laparoscopic repair.

The work has been reported in line with the SCARE criteria and cite the following paper in my references [1].

Presentation of case

We report a case of a 79 year-old-man who was admitted with a complaint of recurrent left abdominal pain. Computed tomography revealed an encapsulated cluster of jejunum loops in the left upper quadrant, near the ligament of Treitz and posterior to the inferior mesenteric vein (Fig. 1, Fig. 2). Emergency laparoscopic surgery was performed. With the patient in the spine position, four trocars were placed through the abdominal wall. The first trocar was placed into the umbilicus for the laparoscope. The next two trocars were placed into the right and left lower abdomen for the operator. The last trocar was placed into the left upper quadrant for retraction. The jejunum loops incarcerated in the hernia sac was reduced without widening of the hernia orifice, which measured 5 cm in diameter. They had ischemic changes, but after reduction bowel color improved and seemed to be viable. Thus, we made judgement the bowel resection was not needed. The hernia orifice was closed intracorporeally with 4 interrupted sutures, taking care not to injure the duodenojejunal flexure medially and the inferior mesenteric vein laterally (Fig. 3, Fig. 4). Postoperative period was uneventful and the patient was discharged home on the 7th postoperative day. There has been no recurrence during a follow-up.

Fig. 1

Horizontal abdominal CT.

Enhanced horizontal abdominal CT shows encapsulated cluster of jejunum loops in the left upper quadrant surrounded by hernia sac (arrowhead) posterior to the inferior mesenteric vein (arrow).

Fig. 2

Coronal abdominal CT.

Enhanced coronal abdominal CT shows encapsulated cluster of jejunum loops in the left upper quadrant (arrowhead).

Fig. 3

Laparoscopic surgical findings.

The hernia orifice was found near the ligament of Treitz, posterior to the inferior mesenteric vein (arrowhead). It was 5 cm sized in diameter.

Fig. 4

Laparoscopic surgical findings.

The hernia orifice was closed intracorporeally with 4 interrupted suture.

Discussion

Paraduodenal hernia is an internal hernia which form the peritoneal cavity near the ligament of Treitz, localizing into a fossa (Landzert’s fossa) to the left of the fourth part of the duodenum, posterior to the inferior mesenteric vein and to left branches of the middle colic artery. The etiology may involve bowel malrotation during the embryonal period and maladhesion between the mesocolon and retroperitoneum [2,3]. Paraduodenal hernias are the most common internal hernias, accounting for approximately 30–53% of cases [4]. There are right and left paraduodenal hernias from the difference in anatomical location and embryological origin. The left paraduodenal hernia is about three times more frequent than the right paraduodenal hernia [5].

Clinical symptoms are unspecified and clinical diagnosis is usually difficult. Some patients have vague abdominal complaints [6,7], while others present with acute abdominal pain for closed loop obstruction and intestinal ischemia.

To make the diagnosis, CT is most useful, which shows a cluster of dilated loops in the left upper quadrant and posterior to the inferior mesenteric vein. Furthermore, Valiability of the bowel can be evaluated with enhanced CT [[8], [9], [10]]. Small bowel contrast study also can be useful. For left paraduodenal hernia, the small bowel is usually located to the left of midline with a well-circumscribed border [11].

At least 50% of patients with paraduodenal hernia ultimately develop intestinal obstruction, so the surgery is recommended for all cases of paraduodenal hernia.

The basic principles of surgery for paraduodenal hernias are reduction of the hernia contents and repair of the defect by either closure or wide opening of the hernia orifice. Left paraduodenal hernias can usually be reduced manually without difficulty, as in the present case, and simple closure of the hernia orifice is sufficient, taking care to avoid vascular injury. If wide opening of the hernia orifice is chosen, the hernia ring can be divided for incising the mesentery parallel to the course of the inferior mesenteric vein. In our case, we thought that wide opening of the hernia orifice leads to the recurrence. Therefore, we chose closure of the hernia orifice.

Until 2018, we found the 31 cases of laparoscopic repair for left paraduodenal hernia described in 26 published reports based on PubMed search for all English articles (Table 1). There were 21 males and 10 females, 1 was not stated. The mean age was 45 years old. The mean size of hernia orifice was 4.1 cm in diameter. Bowel resection was not needed for all patients. Wide opening of hernia orifice was selected for 5 patients [[12], [13], [14], [15], [16]], and closure of hernia orifice was selected for 25 patients. The mean post operative hospital stay was 3.7 days. The operative complications were one case of inferior mesenteric vein injury and one case of recurrence [3]. The inferior mesenteric vein was ligated with clips and divided with ultracision shears along with the ascending branch of the inferior mesenteric artery. The recurrence case was a female patient who visited the hospital, suffering from symptoms of subacute bowel obstruction 18 months after first operation. Laparoscopic operation was performed, and a small patch of Gore-Tex™ mesh was plugged into the redundant paraduodenal fossa and sutured all around it with 2.0 polypropylene. Using non-absorbable suture for closure of hernia orifice may be adequate, but almost all surgeons selected absorbable suture as well as our case.

Table 1

Reported cases of laparoscopic repair of left paraduodenal hernia.

Case	Year	Author	Sex	Age	Symptom	Emergency or elective surgery	Size of hernia orifice (cm)	Bowel resection	Repair for hernia orifice (open or closure)	Operation time (min)	Blood loss (ml)	Post operative hospital stay (day)	Complications
1	1998	Uematsu et al. [11]	M	44 yo	abdominal pain, nausea	elective	5	－	closure	NS	NS	8	none
2	2000	Finck et al.	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS
3	2004	Fukunaga et al. [6]	M	51 yo	abdominal pain	elective	5	－	closure	140	5	7	none
4	2004	Rollins et al. [7]	M	21 yo	abdominal pain, nausea, weight loss	elective	NS	－	closure	NS	NS	2	none
5	2006	Moon et al. [2]	M	18 yo	abdominal pain, nausea, vomit	emergency	2	－	closure	NS	NS	1	none
6	2007	Shoji et al.	M	60 yo	abdominal pain	elective	3	－	closure	120	50	NS	none
7	2008	Palanivelu et al. [3]	M	NS	NS	elective	NS	－	closure	NS	NS	5	IMV injury
8	2008	Palanivelu et al. [3]	M	NS	NS	emergency	NS	－	closure	NS	NS	2	none
9	2008	Palanivelu et al. [3]	F	NS	NS	elective	NS	－	closure	NS	NS	1	recurrence
10	2008	Jeong et al.	M	52 yo	NS	emergency	NS	－	closure	110	NS	5	none
11	2008	Jeong et al.	F	58 yo	NS	emergency	NS	－	closure	90	NS	5	none
12	2009	Poultsides et al. [8]	F	67 yo	abdominal pain, bilious emesis, obstipation	emergency	NS	－	closure	NS	NS	NS	NS
13	2009	Uchiyama et al. [12]	F	80 yo	abdominal pain	elective	NS	－	open	NS	NS	7	none
14	2010	Khalaileh et al.	F	53 yo	abdominal pain, nausea, vomit	emergency	NS	－	closure	NS	NS	3	none
15	2010	Parmar et al. [13]	M	38 yo	abdominal pain	elective	NS	－	open	NS	NS	3	none
16	2011	Al-Mufarrej et al. [9]	M	42 yo	abdominal pain	elective	NS	－	closure	NS	NS	NS	NS
17	2011	Bernshteyn et al. [14]	M	39 yo	abdominal pain	emergency	NS	－	open	NS	NS	2	none
18	2012	Hussein et al.	F	59 yo	abdominal pain, nausea, bilious vomiting	emergency	5	－	closure	NS	NS	2	none
19	2012	Nam et al.	F	12 yo	abdominal pain	elective	5	－	closure	90	NS	5	none
20	2012	Nam et al.	M	3 mo	severe irritability	elective	NS	－	closure	180	NS	4	none
21	2013	Milani et al. [15]	M	45 yo	abdominal pain, nausea, bilious emesis	emergency	NS	－	open	NS	NS	10	none
22	2013	Siddika et al.	M	35 yo	abdominal pain, nausea, loss of appetite	elective	NS	－	closure	NS	NS	1	none
23	2013	Force et al.	F	25 yo	abdominal pain, nausea, vomit	emergency	NS	－	closure	less than 79	minimal	1	none
24	2014	Lee et al.	F	74 yo	abdominal pain	emergency	3	－	closure	105	NS	4	none
25	2014	Assenza et al. [16]	M	67 yo	abdominal pain, diarrhoea, vomit	emergency	NS	－	open	NS	NS	4	none
26	2015	Lim et al. [7]	F	47 yo	abdominal pain	emergency	NS	NS	NS	NS	NS	1	none
27	2015	Sherman et al.	M	26 yo	abdominal pain	NS	NS	－	closure	NS	NS	1	none
28	2016	Winder et al.	M	34 yo	abdominal pain	elective	4	－	closure	NS	NS	1	none
29	2016	Zizzo et al.	M	43 yo	abdominal pain, nausea, vomit	emergency	NS	－	closure	NS	NS	4	none
30	2016	Kulkarni et al.	M	36 yo	abdominal pain, distension	emergency	3 × 4	－	closure	75	less than 10	3	none
31	2016	Kulkarni et al.	M	42 yo	NS	elective	NS	－	closure	135	60	NS	NS
32	2018	our case	M	79 yo	abdominal pain	emergency	5	－	closure	95	less than 10	7	none

NS: not stated, IMV: inferior mesenteric vein.

Our case was the most elderly male in the already published cases before. We also opted for the laparoscopic surgery with early diagnosis by CT, getting the same benefits, minimal invasiveness, aesthetic advantage and early recovery, as those described by other authors despite of elderly case.

All authors indicated that the laparoscopic repair of left paraduodenal hernia resulted in less postoperative pain, earlier intake of diet, shorter hospital stay, cosmetic satisfaction. It is considered that the laparoscopic repair of left paraduodenal hernia is comparatively safe and feasible because of its minimal invasiveness and aesthetic advantage.

Conclusion

Laparoscopic repair of paraduodenal hernia is safe and feasible. It is recommended as the first surgical option for left paraduodenal hernia.

Conflicts of interest

I have no conflicts of interest.

Funding

I don’t have any sources of funding for my research.

Ethical approval

No ethical approval was needed for this case study in our institution.

Consent

Informed consent was obtained from the patient for publication of this case report and accompanying images.

Author contribution

MW, SK and TT drafted the manuscript, contributed to patient care. All authors have read and approved the final manuscript.

Registration of research studies

I don’t have UIN of this case report.

Guarantor

Satoru Kono.

Provenance and peer review

Not commissioned, externally peer-reviewed.