Left paraduodenal hernia: an unusual cause of small-bowel obstruction

Paraduodenal hernias are quite difficult to diagnose. Presentation can range from acute intestinal obstruction (which is the most common clinical presentation) to a long history of vague abdominal pain, often relieved by changes in position,2,3,7 to an incidental finding at laparotomy or autopsy.1 U...

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Bibliographic Details
Published in:Canadian Journal of Surgery 2001-12, Vol.44 (6), p.455-457
Main Authors: Manji, R, Warnock, G L
Format: Article
Language:English
Subjects:
Adult
Brief Communication
Hernia, Ventral - complications
Hernia, Ventral - congenital
Hernia, Ventral - diagnostic imaging
Hernias
Humans
Intestinal Obstruction - diagnostic imaging
Intestinal Obstruction - etiology
Intestine, Small - diagnostic imaging
Male
Radiography
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Summary:Paraduodenal hernias are quite difficult to diagnose. Presentation can range from acute intestinal obstruction (which is the most common clinical presentation) to a long history of vague abdominal pain, often relieved by changes in position,2,3,7 to an incidental finding at laparotomy or autopsy.1 Unfortunately, investigations, unless done at the time of acute obstruction, are often unhelpful because often the hernia has reduced itself; the sufferer is then labelled as having psychosomatic illness.2 Plain radiographs may show a circumscribed, ovoid mass of multiple jejunal loops occupying the left upper quadrant immediately lateral to the ascending duodenum for a left paraduodenal hernia.3 For a right paraduodenal hernia, there may be an ovoid grouping of several small-bowel loops just lateral and inferior to the descending duodenum.3 Small-bowel follow-through radiographs can be useful (as in our patient), and small bowel may be seen herniated through the defect in the transverse mesocolon. If CT is done, for a left paraduodenal hernia, a focal cluster of small bowel may be seen abnormally positioned posterior to the stomach and to the left of the fourth portion of the duodenum.7 Paraduodenal hernias, although rare in clinical practice, are the commonest congenital internal hernias, with over 400 cases having been reported in the literature.2 They account for 0.2% to 0.9% of small-bowel obstructions2 and a death rate of around 20%. Males are affected 3 times more often than females.3 The average age at the time of presentation is 38.5 years.4 There are 2 types of paraduodenal hernias: left sided and right sided. The left-sided hernias are more common, representing 75% of cases.2 They involve the paraduodenal fossa of Landzert, which is located lateral to the fourth segment of the duodenum and posterior to the inferior mesenteric vein and left colic artery.3 This fossa of Landzert is a fold seen in 2% of autopsies.2 Right-sided paraduodenal hernias make up 25% of cases and involve the mesentericoparietal fossa of Waldeyer, which is just lateral and inferior to the descending duodenum.3 The superior mesenteric artery and ileocolic branches are situated in the inferior wall of the right paraduodenal hernia sac.5 This fossa is an abnormal fold reported to be present in about 1% of autopsies.2
ISSN:0008-428X
1488-2310