PICTURES IN DIGESTIVE PATHOLOGY

 

Atypical left paraduodenal hernia

Hernia paraduodenal izquierda atípica

 

 

M. Socas Macías, J. M. Álamo Martín, J. M. Suárez Grau, G. Suárez Artacho, 
A. Tejada, J. Martín Cartes, J. M. Hissnard Cadet, M. Bustos, 
J. D. Tutosaus Gómez and S. Morales Méndez

Service of General Surgery. University Hospitals "Virgen del Rocío" and "Hospital General". Sevilla, Spain

 

 

Case report

A 47-year-old man came to the hospital because acute abdominal pain and vomits. The patient had suffered from episodes of intestinal obstruction since adolescence, and has been studied by a gastroenterologist who found no abnormalities. These episodes have been solved spontaneously in nearly all occasions. However, he had come to the emergency room for the same reason twice last year. The exploration showed abdominal distension and tympanism in the epigastrium. There were neither laparotomic scars nor hernia defects in the abdominal wall. Abdominal X-rays showed air-fluid levels at the small bowel, and marked distension in the proximal and medium jejunum. Gastrointestinal X-ray series with gastrographin showed no abnormal findings. After 48-72 hours the patient persisted with the same complaints, and we decided to operate. During the operation we found a congenital malformation: an intestinal hernia of jejunum inside a peritoneal sac formed by a peritoneal flap of the left mesentery (Fig. 1), as well as an abnormal implantation of the mesentery above the rectum. We performed a resection of the peritoneal sac (Fig. 2) and the adherences inside it. The postoperative period was normal.

 

Discussion

Paraduodenal hernias are rare congenital malformations, but they are the most frequent cause of internal hernias (50% of them). They are caused by a failure in the intestinal rotation, and by an asynchronism in the future development of adhesion of the mesocolon. In right paraduodenal hernias, the small bowel is placed totally or partially behind the ascending mesocolon; in left paraduodenal hernias or mesocolic hernias, which are more frequent than the right ones, the small bowel is placed behind the descending mesocolon (1). We present a rare case of a paraduodenal sac formed by a peritoneal membrane extending from the left side of the mesentery to the descending colon involving a large part of the jejunum, which was not behind the mesocolon as it usually is. Although this is a congenital problem, it is usually diagnosed around the age of 38 years (2). Symptoms vary from recurrent atypical abdominal pain to total intestinal obstruction; however, this condition may be asymptomatic (3). The diagnosis is difficult - CT scans and intestinal follow-throughs are the most sensitive tests, but the condition is usually diagnosed during urgent laparotomy (4). When we operate on a patient with a small bowel obstruction, and the patient has not been operated on before and has no external hernias, we must bear this possibility in mind. Early intervention allows a good postoperative course, as complications due to hernia incarceration are avoided (5).

References

1. Forgacs B, Istvan G, Sugar I, Ondrejka P. Uncommon case of incomplete left paraduodenal hernia. Magy Seb 2003; 56 (6): 243-6.

2. Morán JM, Salas J, Sanjuán S, Amaya JL, Rincón P, Serrano A, et al. Paramesocolic hernias: consequences of delayed diagnosis. Report of three new cases. J Pediatr Surg 2004; 39 (1): 112-6.

3. Ramachandran P, Sridharan S. Strangulated left paraduodenal hernia in an infant. Pediatr Surg Int 2003; 19 (1-2):120-1. Epub 2003 Mar 29.

4. Dritsas ER, Ruiz OR, Kennedy GM, Blackford J, Hasl D. Paraduodenal hernia: a report of two cases. Am Surg 2001; 67 (8): 733-6.

5. Huang YC, Chen HL, Hsu WM, Chen SJ, Lai MW, Chang MH. Left paraduodenal hernia presenting as intestinal obstruction: report of one case. Acta Paediatr Taiwan 2001; 42 (3): 172-4.