Savni Satoskar, MD, Manthan Makadia, MD, Abdul Badr, MD, Sarang Kashyap, MD, Avian Chang, MD, Monzur Haque, MD, Harjeet Kohli, MD. Easton Hospital
INTRODUCTION: 300,000 surgeries are done annually in the US for small bowel obstruction, which is most commonly caused by intraabdominal adhesions, malignancy, and hernias. 0.2 to 5.8% of small bowel obstructions are due to paraduodenal hernias. Paraduodenal hernias carry a 50% lifetime risk of incarceration with a mortality of 20 to 50%.
CASE REPORT: The patient is a 78 year old male who presented with severe upper abdominal pain for one day. He was passing flatus and had had a bowel movement the previous day. On examination, the patient was tender over the upper abdomen. Computed tomography (CT) scan with IV contrast showed a mesenteric swirl sign. The decision was made to perform diagnostic laparoscopy with possible small bowel resection.
Intraoperatively, a mesenteric defect was noted posterior and to the right of the duodenum, through which bowel was herniating. The herniated bowel and its mesentery were edematous. The defect was sutured closed, taking seromuscular and mesenteric bites through the stomach, jejunum, and mesentery. The patient had an uneventful recovery postoperatively and was discharged on postoperative day 2. He returned on postoperative day 28 with periumbilical pain which resolved with conservative management. He was followed up 6 weeks postoperatively and was doing well.
DISCUSSION: Paraduodenal hernias are the most common internal hernias. They are seen more often in males. They are caused by failure of the counterclockwise rotation of the prearterial segment of the embryonic midgut in weeks 2 to 12 of embryonic development. Paraduodenal hernias usually present with chronic intermittent abdominal pain, weight loss, nausea, and vomiting. They may present acutely with symptoms of bowel obstruction. Peritoneal signs are often not appreciated due to retroperitoneal position of the hernia. CT scan of the abdomen often shows clustering of bowel loops, which cannot be displaced on repositioning the patient. If imaging is equivocal, diagnostic laparoscopy may be undertaken.
Surgical correction consists of reducing the bowel, resecting nonviable segments, and either closing the defect or opening the sac laterally into the general peritoneal cavity. In summary, paraduodenal hernias are a rare cause of bowel obstruction and as such present a challenge in diagnosis and early intervention.
REFERENCES: Laparoscopic Repair of a Right Paraduodenal Hernia (2009) James Bittner et al PMID PMC3015939
Right Paraduodenal Hernia in an Adult Patient: Diagnostic Approach and Surgical Management (2011) Carlos M. Nuño-Guzmána José et al PMID PMC3180666
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87084
Program Number: P175
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster