Right paraduodenal hernia: report of two cases and review of literature

Abstract

Paraduodenal hernia (PDH), a rare congenital anomaly, is a type of internal hernia which occurs due to a defect in the reduction and rotation of the midgut. On anatomical and embryological basis, PDH can be broadly divided into right- and Left PDH. Right PDH is rarer than its counterpart. We present two cases of Right PDH. The patientsy presented with a history of recurrent intestinal obstruction since childhood, which was managed conservatively, without a definitive diagnosis. Once they presented to us, a detailed clinical history and a barium meal follow- through clinched the diagnosis of PDH. Intra-operative findings correlated well with the clinical diagnosis. The jejunal loops had herniated through the fossa of Waldeyer. Reduction of hernia contents and excision of the hernia sac was carried out. Post-operatively, the patients are healthy and symptom-free at 4 and 3 years follow-up, respectively. The rarity of this condition and the need for early diagnosis, to prevent the high risk of bowel obstruction and strangulation, makes PDH one of the difficult challenges for the clinicians.

Keywords: internal hernia; paraduodenal hernia; small bowel obstruction.

Figure 1.

A line diagram depicting the anatomical positions of the colon and fossae formed by fusion of the peritoneal and mesenteric folds: a) the fossa of Waldeyer: where the Right PDH occurs; b) the fossa of Landzert, where the Left PDH occurs; c) the retroduodenum, from where the hernia occurs, and d) the hernial orifice.

Figure 2.

Intra-operative photograph of Case 1, showing a thin hernial sac (marked by an arrow) enclosing the small bowel.

Figure 3.

A plain erect abdominal X-ray of Case 2, showing right paraduodenal hernia. The opening of the fossae of Waldeyer is marked by arrow a). small bowel loops are clustered to the right of the midline (marked by arrow b), in a well circumscribed hernial sac.

Figure 4.

Intra-operative photograph of Case 2: a) showing the hernial sac and its relationship with the superior mesenteric and inferior mesenteric veins; b) showing delivery of incarcerated small bowel loops from the hernial orifice (marked by the arrow).

Figure 5.

A line diagram showing the anatomical landmarks in a right paraduodenal hernia: a) the first part of the duodenum; b) the transverse colon; c) the hernial sac forming the fossae of Waldeyer; d) the superior mesenteric vein; e) the inferior mesenteric vein; f) the mesentery of the herniated bowel and g) the hernial orifice.