Journal of Surgery (ISSN: 2575-9760)

case report

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Atypical Causes for Vague Abdominal Pain: Para Duodenal Hernias (Case Report and Review of Literature)

Mohammad Al Yaseen1*, Moamena El-Matbouly2, Abdelrahman Alkurd1, Tamer Elbakary3, Ahmed Suliman1, Ahmed Z Al-Bahrani1

1 Hamad Medical Corporation, Doha, Qatar

2 Hamad Medical Corporation, Weill Cornell Medical College, Doha,Qatar

3 Wakra Hospital- affiliated with Hamad Medical Corporation, Doha,Qatar

*Corresponding author: Mohmmad Al Yaseen, Hamad Medical Corporation, P.O.Box: 3050, Doha, Qatar

Received Date: 12 October, 2022

Accepted Date: 21 October, 2022

Published Date: 25 October, 2022

Citation: Yaseen MA, El-Matbouly M, Alkurd A, Elbakary T, Suliman A, et al. (2022) Atypical Causes for Vague Abdominal Pain: Para Duodenal Hernias (Case Report and Review of Literature). J Surg 7: 1604. DOI: https://doi.org/10.29011/2575-9760.001604

Abstract

Introduction: Internal hernia is a relatively uncommon condition and is a rare type of intestinal obstruction. Paraduodenal hernia is considered the most common type of internal hernias. The rare prevalence and the variable symptoms make the clinical diagnosis of paraduodenal hernia a diagnostic challenge. They represent 1% of syndromes that can cause intestinal obstruction.

Material and Methods: Retrospective case series of four patients diagnosed and operated in Hamad General Hospital, Doha, Qatar with a follow up period of one year.

Results and Discussion: Three patients had left-sided paraduodenal hernia and one patient had right-sided paraduodenal hernia. Three patients were diagnosed using CT scan and one pregnant female was diagnosed with an MRI. Two patients were operated laparoscopically and the other two had open exploration and repair of the hernia. Average hospital stay was 4.75 days. All patients recovered well with an average follow up period of 13 Due to the nonspecific clinical picture; diagnosing paraduodneal hernia requires high index of suspicion. Laparoscopic repair of Para duodenal hernia is safe and can be carried out on elective basis for non-obstructed patients. Surgical intervention is the treatment of choice, also in asymptomatic cases, because it reduces the urgent surgery and hence reducing the morbidity and mortality associated with emergency laparotomy.

Keywords: Internal hernia; Intestinal obstruction; Landzert fossa; Minimally invasive hernia repair; Paraduodenal hernia; Waldeyer Fossa

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.

Case

Age/ gender

presentation

Surgical history

Diagnostic modality

Right/Left

open/ laparoscopy

Length of stay

Complication

Follow up

1

24/ male

Colicky abdominal pain, sharp pain with abdominal distention and bilious vomiting

Open appendectomy

CT abdomen with contrast

Left

Laparoscopic converted to open

6 days

Recurrent attack of adhesive intestinal obstruction, managed

conservatively

7 months

2

68/ female

Recurrent attacks of upper abdominal pain, radiating the back

Laparoscopic cholecystectomy.Knee arthroplasty

CT abdomen with contrast

Left

Laparoscopic

5 days

none

12 months

3

38/ female

Abdominal pai, with vomiting,

Laparoscopic cholecystectomy

MRI

Left

Laparoscopic

3 days

none

18 months

4

23/ male

Abdominal pain, vomiting, and obstipation

 

CT abdomen with contrast

Right

Laparoscopic converted to open

5 days

none

16 months

Table 1: Clinical presentation and demographics of patient population.

Author/Year

N of cases

M/F

Right/Left

Diagnostic modality

Elective/ emergency

Open/laparoscopy

repair

Length of stay

Complications

Erdas et al. (2013)

1

34/F

Right

CT scan

Emergency

Laparoscopic

Interrupted slowly absorbable sutures

4

Conversion for bowel distension

Hussein et al. (2012)

1

59/F

Left

CT scan

Emergency

Laparoscopic

2-0 prolene continuous

2

None

Parmar et al. (2010)

1

38/M

Left

CT scan

Elective

Laparoscopic

Sac neck was widened

3

None

Khalaileh et al. (2010)

1

53/F

Left

CT scan

Emergency

Laparoscopic

Nonabsorbable sutures

3

None

Bittner et al. (2009)

1

26/F

Right

CT scan

Emergency

Laparoscopic

Reduction of contents and widening of mesenteric defect

1

None

Uchiyama et al. (2009)

1

80/F

Left

CT scan

Elective

Laparoscopic

Hernia defect widened

7

None

Jeong et al. (2008)

5

52,58,22,58,71,

3M 2F

3-Left 2- right

CT scan

Emergency

Laparoscopic

Interrupted slowly absorbable sutures

2 pts- 5 days 1 pt- 7

day1 pt-

10 days

1 pt- 14 days

2 ileus

Palanivelu et al. (2008)

4

 

3 left/ 1 right

CT scan

1 case:

Emergency

(right PDH)

3: elective

(left PDH)

2-laparoscopic 3- open

3 Interrupted Vicryl sutures+ GORE-

TEX® permanent, nonabsorbable mesh

secured with 2–0 propylene sutures

3

1 IMV injury repaired via ligation of IMV branch of IMA. 1

Recurrence at 18 months; repair with

GoreTex mesh

Shoji ae al. (2007)

1

60/M

Left

CT+ MRI scan

Elective

Laparoscopic

Non-absorbable interrupted sutures

2

None

Moon et al. (2006)

1

18/M

Left

CT scan

Emergency

Laparoscopic

3 interrupted 3-0 silk sutures

1

None

Rollins et al. (2004)

1

21/M

Left

CT scan

Elective

Laparoscopic

Non-absorbable sutures

3

None

Antedomenico et al. (2003)

1

24/F

Right

CT scan

Emergency

Laparoscopic

Opened widely

3

none

Shadhu et al. (2018)

5

68,34,68,40,75/M

1 Right 4 left

CT scan

2 pt-

emergency

3 pt- semi urgent

paroxysmal symptoms

1 Laparoscopic converted to open

4-laparoscopic

1 pt- hernia opened widely 4 pt- closed

defect with interrupted non absorbable sutures

3 pts-7 days 1 pt- 9

days 1

pt – 14 days

(open case)

None

Kulkarnia et al (2016)

2

36&42/M

Left

CT scan

Elective

Laparoscopic

Interrupted 2-0 polyester

3 days

None

Rajput et al (2021)

1

20/F

left

CT scan

Emergency

Laparotomy

PDH neck widened+

closed with interrupted non absorbable silk sutures

4 days

none

Al Otaibi et al (2019)

1

24/F

Left

CT scan

Emergency

Laparotomy

PDH neck widened and sac excised

4 days

none

Kozman & Fisher (2017)

1

15/F

Left

None Acute abdomen post appendectomy

Emergency

Laparotomy

Hernia sac excised and defect closed with 2-0

vicryl and sac used as

patch

5 days

None

Assenza et al (2014)

1

67/M

Left

CT scan

Emergency

Laparoscopic

Incision of the neck of the sac

4 days

None

Kwan et al (2020)

1

18/F

Right

CT scan

Semiurgent

recurrent attacks

Laparoscopic

Running nonabsorbable V-lock+

Gore® BIO-A® Hiatal

Tissue Reinforcement

Biosynthetic absorbable mesh

2 days

None

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

 

Results and Discussion

This is a retrospective case series conducted in a tertiary health centre, Hamad General Hospital, Doha, Qatar.

Patient A presented with 2 days history of colicky abdominal pain, nausea, and bilious emesis. Examination was positive for a palpable bulge in the left upper quadrant, hyperactive bowel sounds, and empty rectum. CT scan showed features of small bowel obstruction due to internal hernia a shown in Figure 1. He underwent diagnostic laparoscopy revealed left PDH. Through midline laparotomy the hernia sac was excised with closure of the defect and he was discharged in a good condition. Post operative course was complicated by recurrent attacks of adhesive bowel obstruction that were managed conservatively. Patient B presented 1 month post laparoscopic cholecystectomy with repeated bouts of abdominal pain for which she was investigated with CT scan which showed left PDH. The bouts of abdominal pain were exacerbated by laparoscopic surgery. She was sent home after diagnostic laparoscopy and reduction of the hernia. She has no complications on 3 months follow up.


Figure 1: A: graphic illustration of boundaries of fossa of Landzert (left PDH), B: graphic illustration of boundaries of fossa of Waldeyer (right PDH).

Patient C is 38-year-old pregnant lady in her 5th 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.

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