Jingjing L Sherman, MD, Daniel Shouhed, MD, Alexandra Naides, BA, Gustavo Ranvier, MD, Daniel Herron, MD. Mount Sinai
This is a video presentation of a laparoscopic of a left paraduodenal hernia repair.
Patient is a 26 male, with no past medical or surgical history, who has been experiencing episodic abdominal pain every 5 years for the last 15 years. He had two episodes in the last 5 months which required emergency room visits. Upper GI series showed a cluster of jejunum just left of the duodenum in the left upper quadrant, consistent with a left paraduodenal hernia. CT scan showed an encapsulated circumscribed mass of small bowel in the left upper quadrant, also consistent with a left paraduodenal hernia.
Paraduodenal hernias can be right or left sided. Right sided paraduodenal hernias are characterized by small bowel herniating posterior to the superior mesenteric vessels through the Fossa of Waldeyer. Jejunum is typically trapped in the right upper quadrant behind the right mesocolon and mesentery of the cecum. In left paraduodenal hernias, bowel passes through the fossa of Landzert. Small bowel is typically trapped between the left mesocolon and the posterior abdominal wall. The free edge of the left mesocolon contains the inferior mesenteric vein as well as the ascending left colic artery.
The abdomen was entered through an incision in the left subcostal region using the optical viewing technique. Six 5mm ports were used in total. The cecum and terminal ileum were identified in the right lower quadrant. The small bowel was ran retrograde until abnormal adhesions were seen between loops of small bowel and the small bowel mesentery. Once this loop of small bowel was reflected towards the right abdomen, an abnormal fusion of the left mesocolon and small bowel mesentery was identified.
A combination of blunt and sharp dissection was used to free the left mesocolon from the small bowel mesentery which revealed the Fossa of Landzert, opening into the hernia. Small bowel was reduced from the hernia. The ligament of Treitz was identified and the defect closed in two layers. A fibrin sealent was applied to further help reinforce the closure
Post operative course
On post operative day #1 the patient underwent an upper GI series that showed the small bowel to be in the correct position. He tolerated a diet and was discharged home on post operative #1. He was seen for follow up at 3 weeks with no complaints
Paraduodenal hernias result from congenital malformations forming potential spaces near ligament of Treitz. They accounted for 30-50% of internal hernias before gastric bypasses were common. Diagnosis can be made on CT scan or upper GI series. In left paraduodenal hernia, CT and UGI series show loops of jejunum in the LUQ, lateral to the fourth portion of duodenum. Right Paraduodenal hernia on CT demonstrates loops of jejunum in the RUQ behind the right mesocolon. Treatment for both types is surgery. Approach can be laparoscopic or open. Important steps of the operation include lysis of adhesions, reduction of the hernia, bowel resection if necessary and closure of the defect.