Introduction

Internal Hernias (IH) are abnormal protrusion of intra-abdominal contents mostly small intestine or omentum through a defect that maybe congenital or acquired. Internal hernia is relatively an infrequent condition accounting for less than 1% of abdominal hernia and is a very rare cause for intestinal obstruction [1]. The types of internal hernia (in decreasing order) are paraduodenal, pericecal, foramen of Winslow, transmesenteric and transmesocolic, pelvic, intersigmoid, retroanastomotic, and transomental hernia. [1,2] In the classic literature Paraduodenal Hernias (PDH) account for approximately 53% of all cases of internal hernias [2]. Internal hernias are rare and the diagnosis is most often carried out intraoperatively. However, knowledge of the different varieties of internal hernias is fundamental to consider a preoperative diagnosis [2]. Although uncommon; they can potentially represent a surgical emergency since the bowel entrapment in one of those defects can result in intestinal obstruction that can further progress to bowel strangulation and ischemia. The clinical manifestation can range from vague epigastric pain, to abdominal distention with nausea and vomiting leading to sepsis or septic shock in presence of bowel strangulation and ischemia [3]. We present case series of four patients diagnosed with paraduodneal hernia and treated in Hamad General Hospital, Doha-Qatar the main tertiary hospital in the country.

Material and Methods

Retrospective chart review and analysis of all elective and emergency cases admitted and operated in Hamad General Hospital in Doha-Qatar; the main tertiary hospital in the country from Jan-2020 until Jan- 2022. We included the cases with diagnosis of paraduodernal hernia and identified 4 patients. Two researchers reviewed the literature separately including research engines like PubMed and google scholar. The studies included in the literature review are displayed in Tables 1,2.

Table 1: Clinical presentation and demographics of patient population.

Table 2: literature review of reported cases of Para duodenal hernia.

Patient C is 38-year-old pregnant lady in her 5^th month of pregnancy came to the emergency department with abdominal pain and vomiting. MRI showed left para duodenal hernia. Diagnostic laparoscopy confirmed the presence of left PDH, laparoscopic repair of the hernia done. She was discharged in a good condition with good post operative course. Patient D is a 22-year-old healthy male patient with severe abdominal pain, bilious emesis, and obstipation. Diagnostic laparoscopy showed severe bowel distension with right PDH. Conversion to open surgery to avoid bowel surgery, the hernia sac excised and the defect was repaired. Patient discharged home in a good condition as well and satisfactory follow up outcome. PDH hernias are the most frequent internal hernias, they affect men three times more often than women [2]. Despite classically paraduodenal hernia has been described as the most common type of IH, recently transmesenteric hernias have reached a higher incidence, in relation to the increasing frequency of surgical procedures in which a Roux-en-Y loop is constructed [3]. Their diagnosis is usually made intraoperatively; however, with the development of medical imaging and in particular of CT and magnetic resonance imaging, preoperative diagnosis is nowadays possible [3].

Kozman and fisher have reported the first case of left PDH that is exacerbated by laparoscopy, and we are reporting the second case (patient B) who had an exacerbation of her left PDH following laparoscopic cholecystectomy. There are only occasional reports of PDH in young females. Al Otaibi et al reported LPDH in young female patient [4]. Kozman and Fisher reported a case of LPDH post laparoscopic appendectomy in a 15-yearold female patient [5]. We also report an unusual case of left PDH in a young pregnant female as well as in an elderly female post laparoscopic cholecystectomy. Abdominal CT is a gold standard to provide the correct diagnosis: left hernia have a characteristic appearance of clustering of small bowel loops in a saclike mass with encapsulation at the ligament of Treitz, engorgement and crowding of the mesentery vessels with frequent right displacement of the main mesenteric trunk, anterior and upward displacement of the inferior mesenteric vein that lie in the ventral circumference of the hernia orifice and depression of the transverse colon [6-8]. While right PDH have an appearance of saclike mass in the right upper quadrant and the jejunum appeared posterior to the Superior Mesenteric Artery (SMA) and inferior to the third portion of the duodenum [6,8]. Incidence of left PDH (Lanzert’s hernia) is three times higher than of the right subtype (Waldayer’s hernia). Lanzert’s fossa is an area of mesenteric sac between the mesocolon and posterior abdominal wall where small bowel loops may herniate and get trapped. It lies to the left of the fourth part of the duodenum and posterior to the inferior mesenteric vein and the ascending branch of the left colic artery [9,10].

About 10-15% of cases are discovered preoperatively. The abdomen radiography can give information regarding the intestinal segment involved and the extension of the intestinal obstruction; a gastrointestinal series with barium may show dilated loops of small bowel in the upper quadrant, delay of contrast or the point of obstruction [7,10].

Regardless of the approach, basic principles of hernia repair are adopted, namely, reduction of hernia contents and repair of hernia defect. Excision of the hernia sac has been described but is not mandatory given the potential for injury to the colic vessels [3]. Correct identification and preservation of the vascular structures that constitute the hernia neck is essential. The majority of cases of left PDH the neck of the sac is wide and reduction of the small bowel is fairly straightforward in the absence of small bowel obstruction and dilatation. Closure of the hernia defect is recommended when feasible with non-absorbable sutures [3,9,10,11]. Palanivela et al. used a GORE-TEX^® permanent, nonabsorbable mesh secured with 2–0 propylene sutures for recurrence of a left PDH [12]. The authors suggested mesh could be used for large defects and recommended decision based on surgeon experience. Other authors suggested the used of slowly absorbable sutures [13]. Rarely, widening of the hernia neck is required to reduce the contents and even division of the inferior mesenteric vein in more difficult cases [14]. Kwan et al reported using biosynthetic absorbable mesh during initial repair of paraduodenal hernias to reinforce suture line where the defect is large or there is concern over adequacy of suture repair mainly in wide neck hernias [15-19]. This is suggested to reduce the rate of hernia recurrence as well as avoid complications from permanent implants like mesh erosion. Laparoscopic repair is expected to reduce post operative pain, morbidity and length of hospital stay. Moreover, laparoscopic approach provides the added benefit of verification of the diagnosis as well as simultaneous repair of the hernia in cases that could not be diagnosed with radiological methods. During urgent intervention the laparoscopic approach might be difficult due to bowel distention that reduces the operative space and increases the risk for iatrogenic bowel injuries [6,15,16,20].

Conclusion

Due to the nonspecific clinical picture, PDHs require a high index of suspicion and relevant imaging for establishing a correct diagnosis and early intervention. CT scan is the gold standard for establishing the diagnosis. The patients’ profile in most published case reports are elderly age group and males; however, our case series showed presence of PDH in young females as well as young males. Potentially, prior laparoscopic surgeries can accentuate the symptoms of PDH leading to intestinal obstruction. Laparoscopic approach should be considered in hemodynamically stable patients when expertise in advanced laparoscopy is present. The surgical intervention is the treatment of choice, also in asymptomatic cases, because it reduces the urgent surgery and complications related to hernia, that appear in almost half of cases.

References

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