Laparoscopic repair of a right paraduodenal hernia

Abstract

Background and objectives: Right paraduodenal hernia (PDH) results from a primitive gut malrotation. The resultant jejunal mesenteric defect posterior to the superior mesenteric vessels allows decompressed jejunum to herniate retroperitoneally. PDH make up 53% of all internal hernias, but account for only 0.2% to 5.8% of all cases of intestinal obstruction. In addition, PDH exhibits male and left-sided predominance. Ours is the second report to describe the preoperative diagnosis and totally laparoscopic repair of a right PDH.

Methods: We report the case of a 26-year-old female with symptoms suggestive of partial small bowel obstruction and a 6-year history of intermittent abdominal pain. Physical examination demonstrated lower quadrant tenderness. Plain abdominal radiographs and ultrasonography were nondiagnostic. Contrasted computed tomography of the abdomen revealed jejunum encased within the right upper quadrant suspicious for right PDH.

Results: The patient underwent successful laparoscopic right PDH repair and was discharged home on postoperative day 1 without late sequelae.

Conclusions: In the outpatient setting, clinical suspicion and comprehensive radiological investigation permit preoperative diagnosis of right PDH. In acute situations, clinical presentation, plain radiographs, and then diagnostic laparoscopy may be an expeditious diagnostic algorithm. Subsequent laparoscopic repair of right PDH is feasible and may shorten hospital length of stay.

Figure 1.

Helical computed tomography of the abdomen with oral and intravenous contrast demonstrates a right PDH.

Figure 2.

(A) The illustration of normal adult anatomy shows (A) proximal and (B) distal segments of jejunum relative to the superior mesenteric artery (SMA) and vein (SMV). B) Representation of a right paraduodenal hernia demonstrates (A) proximal and (B) distal segments of jejunum posterior and to the right of the SMA and SMV.

Figure 3.

The depiction illustrates a patent Waldeyer's fossa in the root of the small bowel mesentery complete with herniated (A) proximal and (B) distal segments of jejunum.

Figure 4.

Trocar size and positioning used for laparoscopic repair are shown.

Figure 5.

A laparoscopic view shows the duodenum and ligament of Treitz as well as the (A) proximal segment of jejunum, which passes through Waldeyer's fossa, and the (B) distal segment of jejunum.

Figure 6.

Following reduction of the small bowel and mobilization of the right colon, a small bowel mesenteric defect is identified and opened fully.

Figure 7.

Blunt-tip forceps inserted in a medial-to-lateral fashion demonstrate a widely patent defect.

Figure 8.

Stage 15 (day 33) of right paraduodenal hernia development where Duo = duodenum, Pre-A = prearterial limb and Post-A = postarterial limb of gut, SMA = superior mesenteric artery, and YS = yolk stalk.

Figure 9.

Stage 16 (day 37) of right paraduodenal hernia development where Duo = duodenum, Pre-A = prearterial limb and Post-A = postarterial limb of gut, and SMA = superior mesenteric artery.

Figure 10.

Stage 21 (day 52) of right paraduodenal hernia development where SMA = superior mesenteric artery, Prox Pre-A = proximal segment of prearterial limb and Dis Pre-A = distal segment of prearterial limb of gut, Post-A = postarterial limb of gut, Appy = appendix, and Cecal Div = cecal diverticulum.

Figure 11.

Fetal stage (day 70+) of right paraduodenal hernia development where Duo = duodenum, SMA = superior mesenteric artery, Prox Pre-A = proximal segment of prearterial limb and Dis Pre-A = distal segment of prearterial limb of gut, Post-A = postarterial limb of gut, Appy = appendix, and Cecal Div = cecal diverticulum.