Ioana Antonescu, MD, CM, MScEpi, Carmen L Mueller, BScH, MD, FRCSC. McGill University
Background: Internal hernias are an infrequent entity, accounting for only between four and six percent of small bowel obstructions, but being associated with a high mortality rate when strangulated. An error during the second stage of embryological development causes the small bowel to become trapped under the mesentery of the rotating colon, resulting in an internal hernia behind the superior mesenteric artery and inferior to the third stage of the duodenum. This should be repaired given the lifelong risk of incarceration and strangulation.
Methods: A 28 year-old lady with no significant medical history presented with 24 hours of abdominal pain. Her symptoms had improved while in the emergency room, her abdominal exam was benign, and her white blood cell count was within normal limits. A CT scan revealed a duodenum that did not cross the midline, the presence of clustered intestinal loops in the right upper quadrant as well as a dilated ileal loop in the right lower quadrant, associated with mesenteric vascular engorgement. These findings were suggestive of a right-sided paraduodenal hernia with the majority of the small bowel herniated into the sac, and the patient was taken to the operating room despite her reassuring clinical status.
Results: This video illustrates the laparoscopic approach for repairing a right-sided paraduodenal hernia. Key steps include division of the lateral attachments of the colon on the right and transfer of the right colon to left side of abdomen. This opens the hernia sac widely and eliminates the defect. The patient tolerated the procedure, was discharged on the second post-operative day, and continued to be well at one-month follow-up.
Conclusion: Right-sided paraduodenal hernias are an extremely rare cause of congenital small bowel obstruction. When identified, they should be repaired due to the inherent risk of strangulation. Repair requires medialization of the right colon to eliminate the hernia defect.