Right para-duodenal hernia related small bowel strangulation in 71 years old male patient managed surgically for small bowel resection and anastomosis:First case report in Somalia

Abstract

Introduction and importance: Para-duodenal hernias make up 53 % of all internal hernias, with 40 % being left-sided and 13 % being right-sided. The occurrence of symptoms in adults is rare, ranging from 0.2 % to 0.5 %. The sex ratio for internal hernia often exhibits a male predominance, with around three males affected for every one female. Emergency operations typically result in the discovery of the right para-duodenal hernia, an uncommon internal hernia with aberrant anatomy. In this case report, we conducted a comprehensive analysis of right para-duodenal hernia. This condition poses a diagnostic challenge and requires prompt surgical management in emergency patients.

Case presentation: A 71-year-old male presented to the emergency department with a 24-h history of intermittent abdominal pain in the abdominal region. The patient described the pain as colicky and reported experiencing nausea and vomiting. All laparotorical investigations were normal. A CT scan showed that the jejunal bowel loops were positioned incorrectly, with one below and to the right of the second part of the duodenum and the other at an incorrect angle to the duodenum-jejunal junction. We diagnosed a suspected para-duodenal hernia. An emergency operation was scheduled, and instead a diagnosis of right para-duodenal hernia was made. Following the surgery, the patient made a full recovery and received discharge within 5 days.

Clinical discussion: Internal hernias are a rare and unusual type of intestinal obstruction that are defined by the small bowel becoming trapped in an abnormal intra-abdominal cavity defect. Less than 1 % and up to 6 % of all related bowel obstruction, respectively, are roughly related. In our cases, due to the late presentation of massive abdominal distention, peritonitis, and hemodynamic alterations, we preferred an explorative laparotomy, which revealed intestinal ischemia, which is trapped in the hernia sac and is not suitable for laparoscopic surgery.

Conclusion: Although right para-duodenal hernia is a very uncommon type of para-duodenal hernia, its anatomical features can vary significantly. It is critical to increase healthcare professionals' knowledge about the illness and ensure prompt diagnosis and surgical intervention. This intervention will effectively mitigate potential problems and significantly enhance patient outcomes.

Keywords: Bowel ischemia; Bowel obstruction; Preduodenal hernia; Resection and anastomosis.

Figs. 1, 2

Chest and abdominal X-ray shows that there is no air diaphragm but demonstrates multiple air fluid level which shoes bowel obstruction.

Fig. 3

Abdominal CT-scan shows gastric dilatation for proximal bowel obstruction.

Figs. 4, 5

Abnormal orientations of the jejunal bowel loops being interposed below and to the right of the second part of the duodenum associated with an abnormal position of the duodeno-jejunal junction, with multiple air-fluid levels, denoting closed loop obstruction.

Fig. 6

Identifying the defect of paraduodenal hernia were the bowel is trapped.

Fig. 7

The ischemic part of the bowel.

Fig. 8

The resected part of the small bowel.