Laparoscopic treatment of ventral hernia

Laparoscopic repair of abdominal wall hernias has been introduced recently to treat both spontaneous and incisional hernias with reported good results. In the Mafraq and Al Jaziera Hospitals in the United Arab Emirates, 18 patients have been treated using the laparoscopic technique. These cases included 11 incisional hernias, 5 spontaneous paraumbilical hernias, and 2 combined incisional and paraumbilical hernias. A bilayer repair was performed in all cases using a layer of polyester mesh to bridge the defect and a sheet of Gore-Tex (W. L. Gore & Associates, Flagstaff, AZ, USA) to prevent adhesions between first layer and the bowel. Seroma at the hernia site was the most frequent postoperative complication. Hospital stay ranged from 2 to 7 days (mean, 3.2 days). Recurrent hernia developed in one patient after a mean follow up of 22.3 months. This technique is in its evolution. Long follow-up evaluation is required before the effect on recurrence is known, and further development regarding the composition of prosthetic biomaterials and the methods of its fixation is expected. Received: 4 February 2000/Accepted: 11 May 2000/Online publication: 28 September 2000     

Uncommon case of incomplete left paraduodenal hernia

Internal hernias are very rare. The hernial orifice, sac and content are situated inside the abdomen. Paraduodenal hernias are relatively rare congenital malformations and account about 50 per cent of all internal hernias. The cause of this malformation is the incomplete rotation of the mid-gut. Right and left paraduodenal hernias are different, varying in anatomic structure and embryological origin. In right paraduodenal hernia the small bowel is partially or completely localised behind the mesocolon of the ascending colon, in left paraduodenal hernia behind the mesocolon of the descending colon. That is why the widely used name "mesocolic" hernia is more convenient, because it refers on the pathogenesis of the disorder. The complaints can vary from recurrent atypical abdominal pains to the complete small bowel obstruction, but often there are no complaints. Abdominal CT scan and the barium meal provide the best diagnostic approach for paraduodenal hernias, but it will be recognised very often only at an emergency operation. A case of small bowel obstruction caused by incomplete left paraduodenal hernia discovered after swallowing a foreign body is described with pathogenesis, diagnosis and possible treatments for the disease.     

Paraduodenal hernia: an uncommon cause of recurrent abdominal pain

Internal abdominal hernias are a rare entity and may cause unexplained abdominal pain. This report concerns a 46 year old male patient, with a four year history of episodic colicky peristaltic abdominal pains, in whom a left paraduodenal hernia was found at surgical exploration after a negative diagnostic screening by ultrasound, CT and small bowel enema. Upon laparotomy the Authors found a left-sided paraduodenal hernia with an empty herniated sack. Repair of the hernial defect resulted in the complete and stable resolution of abdominal symptoms. The importance of considering paraduodenal hernias in the differential diagnosis of unexplained intermittent abdominal pain is discussed.     

Left Paraduodenal Hernia Causing Small Bowel Obstruction

A case of small bowel obstruction secondary to a left paraduodenal hernia is illustrated together with its radiological features and intra-operative appearance. Paraduodenal hernias are rare congenital causes of small bowel obstruction, and various approaches to surgical treatment are available including conventional open and minimally invasive laparoscopic techniques. This case presents one possible option for surgical management and briefly reviews the literature for the various surgical techniques and strategies available to the surgeon when faced with a left paraduodenal hernia.     

Laparoscopic management of left paraduodenal hernia

Internal herniation of small bowel accounts for about 1% of all the patients with intestinal obstruction. Fifty percent of the patients with paraduodenal hernia will have bowel obstruction. Left paraduodenal hernia resulting from abnormal rotation of the midgut during embryonic development is the most common form of congenital internal hernia. A case of a young male presenting with chronic abdominal pain due to left paraduodenal hernia is being reported. A correct preoperative diagnosis of left paraduodenal hernia was made on computerised tomography (CT), and the patient was managed by laparoscopic surgery. The role of imaging in preoperative diagnosis is being highlighted with a brief review of literature.     

Laparoscopic approach to incarcerated inguinal hernia

The safety and effectiveness of laparoscopic treatment for incarcerated inguinal hernia have not been clarified. Six patients who underwent laparoscopic reduction and repair of incarcerated inguinal hernias were reviewed retrospectively. All operations were initiated within 1 h after establishment of the diagnosis. Laparoscopically, the incarcerated small-bowel segments could be easily returned to the abdominal cavity by a combination of pulling them with Babcock forceps while pushing back the bowels from outside the abdominal wall. The hernial portals were not cut in three patients, while they were dissected in the other three. All incarcerated bowels were congested and red immediately after reduction; however, their color returned to normal during hernia repair and unnecessary bowel resection was therefore avoided. The mean operation time was 88 min. Although one patient underwent laparotomy because of the suspicion of necrosis of the incarcerated inguinal hernia, which was finally found to be due to postoperative paralytic ileus, the postoperative courses of the remaining five were uneventful. Laparoscopic reduction and repair of incarcerated inguinal hernia was useful, and unnecessary bowel resection could be avoided. Received: 9 February 1996/Accepted: 20 May 1996     

Laparoscopic ventral hernia repair

Introduction: Effective surgical therapy for ventral and incisional hernias is problematic. Recurrence rates following primary repair range as high as 25–49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. As an alternative, laparoscopic techniques offer the potential benefits of decreased pain and a shorter hospital stay. This study evaluates the efficacy of the laparoscopic approach for ventral herniorrhaphy. Methods: A retrospective review was performed for 100 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 1995 and May 1998. All patients who presented during this period and were candidates for a mesh hernia repair were treated via an endoscopic approach. Results: One hundred patients underwent a laparoscopic ventral hernia repair. There were 48 men and 52 women. The patients were typically obese, with a mean body mass index (BMI) of 31 kg/m². Each had undergone an average of 2.5 (range; 0–8) previous laparotomies. Forty-nine repairs were performed for recurrent hernias. An average of two patients (range; 1–7) had previously failed open herniorhaphies; in 20 cases, intraabdominal polypropylene mesh was present. There were no conversions to open operation. The mean size of the defects was large at 87 cm² (range; 1–480). In all cases, the mesh (average, 287 cm²) was secured with transabdominal sutures and metal tacks or staples. Operative time and estimated blood loss averaged 88 min (range; 18–270) and 30 cc (range; 10–150). Length of stay averaged 1.6 days (range; 0–4). There were 12 minor and (two) major complications: cellulitis of the trocar site (two), seroma lasting >4 weeks (three), postoperative ileus (two), suture site pain > 2 weeks (two), urinary retention (one), respiratory distress (one), serosal bowel injury (one), and skin breakdown (one) and bowel injury (one). Both of the latter complications required mesh removal. With an average follow-up of 22.5 months (range; 7–37), there have been (three) recurrences. Conclusion: The laparoscopic approach to the repair of both primary and recurrent ventral henias offers a low conversion rate, a short hospital stay, and few complications. At 23 months of follow-up, the recurrence rate has been 3%. Laparoscopic repair should be considered a viable option for any ventral hernia. Received: 11 February 1999/Accepted: 15 March 2000/Online publication: 28 April 2000     

Laparoscopic extraperitoneal inguinal hernia repair

We have devised a reproducible approach to the preperitoneal space for laparoscopic repair of inguinal hernias that is based on an understanding of the abdominal wall anatomy. Laparoscopic totally extraperitoneal herniorrhaphy was performed on 99 hernias in 90 patients at the Los Angeles County–University of Southern California Medical Center, using a standardized approach to the preperitoneal space. Operative times, morbidity, and recurrence rates were recorded prospectively. The median operative time was 37 min (range, 28–60) for unilateral hernias and 46 min (range, 35–73) for bilateral hernias. There were no conversions to open repair, and there was only one conversion to a laparoscopic transabdominal approach. Complications were limited to urinary retention in two patients, pneumoscrotum in one patient, and postoperative pain requiring a large dose of analgesics in one patient. All patients were discharged within 23 h. There were no recurrences or neuralgias on follow-up at 2 years. A standardized approach to the preperitoneal space based on a thorough understanding of the abdominal wall anatomy is essential to a satisfactory outcome in hernia repair. Received: 18 November 1998/Accepted: 19 March 1999     

Treitz’s hernia

Treitz’s hernia is the eponymous name for a paraduodenal hernia. These are rare hernias that arise in the potential spaces and folds of the posterior parietal peritoneum adjacent to the ligament of Treitz. Presentation may be acute with small bowel obstruction or bowel ischaemia, or with chronic intermittent abdominal pain. Treatment is by surgery, due to the high (50%) lifetime risk of obstruction. Here, we present two cases from our own institution and review the literature regarding the embryology, anatomy, cross-sectional imaging and surgery of these fascinating hernias.     

An unusual cause of small bowel obstruction in the elderly

Paraduodenal hernia is an unusual form of internal hernia that results from a congenital midgut malrotation. It is classified as either right or left, depending on anatomic features, and embryologic origin. Left hernias are three times more common than right. Clinical symptoms may be intermittent and non-specific, as nausea, distension and abdominal pain or sometimes acute small bowel obstruction or ischemia. The average age at diagnosis is usually 38 years. We report a case of right paraduodenal hernia in a 79 years old man admitted to the emergency department with an acute small bowel obstruction.     

Laparoscopic surgery for left paraduodenal hernia

Paraduodenal hernia is a rare condition but the most common internal hernia. We describe the case of a 51-year-old man who was admitted with a complaint of 2 months' duration of recurrent left lower abdominal pain. Left paraduodenal hernia complicated by bowel malrotation was diagnosed, and the patient underwent laparoscopic surgery since no bowel necrosis was observed. The bowel incarcerated in the hernial sac was reduced, and an Endostitch was used to close the hernial orifice with continuous sutures. The postoperative course was good, and the patient was discharged 7 days after surgery. For paraduodenal hernia without bowel necrosis, particularly a left hernia, reduction of the incarcerated bowel and closure of the hernial orifice are relatively easy in terms of technique, and laparoscopic surgery may be the surgical method of choice because of its minimal invasiveness and aesthetic advantage.     

A Left Paraduodenal Hernia Causing Acute Bowel Obstruction: a Case Report

We present the case of a 54-year old woman who presented twice at our emergency department with progressive abdominal pain. Over the last few years, multiple short periods of abdominal pain had occurred: the pain always resolved spontaneously after a few hours. She had no past medical history. CT scan revealed a sac-like mass of small bowel loops to the left of the ligament of Treitz, consistent with the diagnosis of a left paraduodenal hernia. On laparotomy, a left paraduodenal hernia with incarceration of small bowel loops was found; the herniated loops were reduced and the hernia orifice closed. The anatomy, treatment and importance of considering this uncommon diagnosis when examining a patient with acute small bowel obstruction are discussed.     

Right paraduodenal hernia leading to bowel strangulation

Up to half of all internal hernias are caused by paraduodenal hernia, a rare congenital midgut malrotation that accounts for less than 1% of all intestinal obstructions. The diagnosis may arise from an incidental finding on abdominal imaging or the patient may present with abdominal pain, vomiting, and obstipation. Early recognition and management of this disease entity are keys because serious complications such as bowel ischemia and infarction may result from a delay in diagnosis. We present a case involving a 14-year-old boy with gangrenous small bowel secondary to right paraduodenal hernia.     

Left-Sided Paraduodenal Hernia: Report of a Case

Paraduodenal hernias are rare congenital malformations consisting of incomplete rotation of the midgut, which may lead to intestinal obstruction or simply be detected as an incidental finding at autopsy or laparotomy. We report a case of left paraduodenal hernia diagnosed preoperatively by computed tomography and operated on in an emergency setting for signs of peritoneal irritation. A misdiagnosis had been made when the patient suffered his first attack 6 months earlier and he had been treated for familial Mediterranean fever. We reduced the small bowel loops from the left paraduodenal hernia sac with ligation and transection of the inferior mesenteric vessels. The patient was discharged from hospital on postoperative day 4 after an uneventful recovery.     

Laparoscopic repair of a right paraduodenal hernia

Background: Laparoscopic repair of a right paraduodenal hernia has never been described in the literature. A 24-year-old woman was admitted after 2 weeks of intermittent abdominal pain associated with nausea and vomiting. Physical examination was normal. Laboratory studies and upper endoscopy were normal. Computed tomography revealed that the small bowel was on the right side of the abdomen and the colon on the left, suspicious for malrotation. Subsequent upper gastrointestinal series with small bowel follow-through revealed the ligament of Treitz on the right with the small bowel encased within a probable hernia sac. A presumptive diagnosis of a right paraduodenal hernia was made.Methods and Results: Initial access was obtained with a 10-mm infraumbilical port followed by placement of 5-mm ports in the right and left upper and lower quadrants. The duodenum was identified and the small bowel was found encased within a hernia sac, which was opened widely from the duodenum to the pelvis. The hernia sac was opened laterally to avoid injury to the superior mesenteric vessels. The small bowel was then released from the sac into the peritoneal cavity. The entire bowel was inspected and no other abnormalities were noted. The patient had resolution of her abdominal pain and her postoperative course was uncomplicated. She was discharged home on postoperative day 3 and has since done exceptionally well.Conclusions: Paraduodenal hernia, a rare cause of small bowel obstruction, can present a diagnostic challenge. However, when the diagnosis is made preoperatively, a laparoscopic repair is a feasible and practical option. Poster presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 12–15 March 2003 This article contains the opinions of the authors only and does not represent the opinions of the U. S. Department of Defense or the U. S. Army.     

Laparoscopic treatment of left paraduodenal hernia in two cases of children

IntroductionThe paraduodenal hernia is an internal hernia that might cause a small bowel obstruction. The laparoscopic repair of paraduodenal hernia is sporadically reported for its safety, convenience, and patient's satisfaction.Presentation of caseWe performed the laparoscopic treatment of the left paraduodenal hernia in two children, a 3-months old boy and 12-year old girl. The girl had a left upper quadrant pain for one month with postprandial nausea after eating. The 3-months boy presented with an intermittent severe irritability. Small bowel series and computed tomography showed the left paraduodenal hernia in two patients. We successfully did the laparoscopic paraduodenal hernia repair using 5 mm and 3 mm laparoscope. They discharged within 5 days, uneventfully.DiscussionDespite of technical difficulties in pediatrics such as small working space and less pneumoperitoneum, the laparoscopic repair for paraduodenal hernia leads to patient's earlier intake of diet and rapid recovery with cosmetic satisfaction. The 3 mm laparoscopic repair needs longer operation time, but it is feasible in infants.ConclusionLaparoscopic repair of paraduodenal hernia in children and infants is safe and feasible. We recommend the laparoscopic repair as the first surgical option for paraduodenal hernia.     

A left paraduodenal hernia causing acute bowel obstruction: a case report

We present the case of a 54-year old woman who presented twice at our emergency department with progressive abdominal pain. Over the last few years, multiple short periods of abdominal pain had occurred: the pain always resolved spontaneously after a few hours. She had no past medical history. CT scan revealed a sac-like mass of small bowel loops to the left of the ligament of Treitz, consistent with the diagnosis of a left paraduodenal hernia. On laparotomy, a left paraduodenal hernia with incarceration of small bowel loops was found; the herniated loops were reduced and the hernia orifice closed. The anatomy, treatment and importance of considering this uncommon diagnosis when examining a patient with acute small bowel obstruction are discussed.     

Incidence of incipient contralateral hernia during laparoscopic hernia repair

Background: In addition to its well-known benefits of decreased postoperative pain and shorter recovery time, laparoscopic hernia repair has the major advantage of allowing the surgeon to explore the side contralateral to the clinically diagnosed hernia. The purpose of this study was to evaluate the incidence of incipient unsuspected contralateral hernia during totally extraperitoneal (TEP) laparoscopic inguinal herniorrhaphy and to analyze the risks and benefits of identifying these hernias at the time of the initial surgery. Methods: We did a retrospective review of the charts of all of the 724 male patients who underwent laparoscopic TEP repair of 958 groin hernias between September 1991 and September 1999. The initial clinical impression of the existence of unilateral or bilateral hernias was noted and compared to our operative findings. The same surgeon performed all the repairs. Exploration of the contralateral side was performed in a systematic fashion. A second mesh prosthesis was placed if a contralateral hernia was found. Results: Bilateral hernia repair was performed on 234 patients (32.3%). In 62 of them (11.2%), the contralateral hernia was diagnosed only at the time of the procedure. Operative time ranged from 14 to 185 min (median, 38.6). The operative time for the contralateral exploration ranged from 2 to 5 min (median, 2.8). The rate of complications was 4.1%, but no complications were directly related to the exploration of the asymptomatic side. Conclusion: Our study shows that a large number of inguinal hernias are undiagnosed by physical examination (11.2%). Systematic contralateral exploration using the TEP approach is safe and does not greatly increase the operative time. Early identification and repair of a contralateral hernia obviates the need for reoperation, reduces overall costs to the health care system, and eliminates any further work loss for the patient. Received: 24 November 1999/Accepted: 3 February 2000/Online publication: 8 May 2000     

Needlescopic extraperitoneal repair of inguinal hernias

Laparoscopic inguinal herniorrhaphy has traditionally been performed using one 5-mm and two 11-mm trocars. In this report, we evaluate the feasibility of the preperitoneal repair of inguinal hernias using the needlescopic method (2-mm ports) and describe the technique used in this repair. A total of 11 inguinal hernias were treated with needlescopic extraperitoneal repair. There were five direct and six indirect hernias. One patient had a bilateral hernia. The average operative time was 54 min. One patient was converted to the standard laparoscopic extraperitoneal method. All patients were discharged a few hours after the procedure. They were able to resume activity within a few days and required only minimal analgesic intake. Follow-up ranged from 1 to 6 months. All patients were followed up by one of the surgeons at 1, 3, and 6 weeks, and then at 6 months. No complications were encountered. There have been no recurrences to date. Overall, needlescopic extraperitoneal repair of inguinal hernias is a feasible procedure in male patients seeking better cosmetic results than can be achieved with standard laparoscopic extraperitoneal repair. This procedure is technically more demanding. The operative time is longer. The cosmetic aspect is the only advantage of this technique. Received: 22 July 1998/Accepted: 13 October 1998     

Left laparoscopic paraduodenal hernia repair

Background

An internal hernia is a protrusion of bowel through a normal or abnormal orifice in the peritoneum or mesentery. Paraduodenal hernia is by far the most common form of congenital internal hernia, making up 53% of all reported cases. In recent years, as surgeons have become more comfortable with laparoscopic techniques, they are performing an increasing number of these procedures laparoscopically.

Methods

To highlight the technical steps of this technique, the case of a patient with a left paraduodenal hernia and a video of the laparoscopic repair are presented. Additionally, a PubMed search of the English medical literature was conducted using the search words “laparoscopic,” “paraduodenal,” and “hernia” as filters. The cases of laparoscopic paraduodenal hernia repair in the literature to date recording data on technique, complications, and hospital course were reviewed.

Results

In addition to the case described in this report, 14 cases of laparoscopic paraduodenal hernia were described in 10 published reports. Of the 15 cases, 11 (73%) were left-sided, likely representing the relative incidence of these cases. The hernia defect was closed in 10 (77%) of the 13 cases for which the repair method was described, whereas the defect was widely opened in the remaining cases. One report described an operative complication (6.7%), an internal mesenteric vein injury, and one recurrence (6.7%) occurred 18 months after surgery in the direct defect closure group.

Conclusion

The current data lead to the conclusion that laparoscopic paraduodenal hernia repair is a safe and feasible approach for selected patients. It can be expected that as surgeons become increasingly comfortable and facile with laparoscopic techniques, paraduodenal hernias and many other causes of acute small bowel obstruction will be increasingly managed laparoscopically.