A causal relationship between right paraduodenal hernia and superior mesenteric artery syndrome: a case report

Abstract

Introduction: Cases of right paraduodenal hernia and superior mesenteric artery syndrome have been reported separately, but their occurrence in combination has not been reported.

Case presentation: A 46-year-old Japanese man who had never undergone laparotomy was admitted to our hospital due to an acute abdomen. An enhanced multidetector-row computed tomography scan of our patient showed a cluster of small intestines with ischemic change in his right lateral abdominal cavity. Emergency surgery was subsequently performed, and strangulation of the distal jejunum along with incidental right paraduodenal hernia was found. His necrotic ileum was resected, and the jejunum encapsulated by the sac was repaired manually without reduction.Three days after the operation, however, our patient developed vomiting. An upper gastrointestinal series revealed a straight line cut-off sign on the third portion of his duodenum. A second enhanced multidetector-row computed tomography scan showed that he had a lower aortomesenteric angle and a shorter aortomesenteric distance compared to his condition before his right paraduodenal hernia was surgically repaired. We strongly suspected that the right paraduodenal hernia repair may have induced superior mesenteric artery syndrome. On the 21st post-operative day, duodenojejunostomy was performed because conservative management had failed.

Conclusions: In this case, enhanced multidetector-row computed tomography, which permits reconstructed multiplanar imaging, helped us to visually identify these diseases easily. It is important to recognize that surgical repair of a right paraduodenal hernia may cause superior mesenteric artery syndrome.

Figure 1

Pre-operative enhanced abdominal multidetector-row computed tomography shows intestinal cluster in the right lateral abdominal cavity. The intestinal wall is edematous and not well-enhanced.

Figure 2

Operative findings show the unfixed hernia orifice by the side of the ligament of Treitz.

Figure 3

Upper gastrointestinal series shows: (A) Upper gastrointestinal series shows stricture of the duodenal third portion with a straight line cut-off sign in supine position. (B) In the prone position, the contrast medium passes through the obstructed part to the distal side of duodenal third portion.

Figure 4

Reconstructed enhanced multidetector-row computed tomography reveals the following:(A) before the surgical repair of the right paraduodenal hernia, the aorto-mesenteric angle is 44°, and the aorto-mesenteric distance is 28 mm. There are intestinal gas bubbles under the aorto-mesenteric junction. (B) After the repair, the aorto-mesenteric angle has narrowed to 14°, and the aorto-mesenteric distance has shortened to 5 mm. Furthermore, no intestinal gas can be seen under the angle.

Figure 5

Post-operative upper gastrointestinal series shows good passage through the anastomosis.

Figure 6

Retrospective multiplanar reconstructed enhanced multidetector-row computed tomography images reveal an abnormal cluster of digestive loops in the right lateral abdominal cavity and mesenteric vessel changes such as twisting and stretching.