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.     

Paraduodenal hernia: a report of two cases

Paraduodenal hernias are uncommon congenital herniations into the mesentery of the colon that present as small bowel obstruction. The diagnosis is elusive but may be made by CT scan or upper gastrointestinal series. There are three types: left, right, and transverse. The repair involves reduction of the hernia and closure of the mesenteric defect in accordance with the anatomy of the hernia. We present two cases of paraduodenal hernia that are representative of this unusual class of internal herniation.     

Left paraduodenal hernia as a rare cause of acute abdomen

Background

Paraduodenal hernias are congenital internal hernias that emerge as a result of the incomplete fusion of the mesentery with the peritoneum and abnormal intestinal rotation during the stages of foetal development. A rare cause of intestinal obstruction, especially in patients with a medical history free of abdominal operations, paraduodenal hernias account for approximately half of the cases of internal hernias and are responsible for 0.2–0.9% of intestinal obstructions.

Case presentation

We hereby report the case of a 39-year-old female patient who presented with a three-hour episode of acute epigastric pain and nausea. Physical examination revealed tenderness and guarding at the palpation of the epigastrium and the left upper quadrant. Computed tomography was suggestive of an internal hernia at the level of the Treitz ligament.

Results

Emergency laparotomy was performed and the incarcerated jejunal loops were restored back to the abdominal cavity, while the defect at the root of the mesentery was suture closed, with care not to include the inferior mesenteric vein. The post-operative period was uneventful.

Conclusion

Though rare, paraduodenal hernias should be included in the differential diagnosis in cases of acute abdomen or upper bowel obstruction, particularly in the absence of previous abdominal surgery. Surgical treatment is similar to that indicated for any other type of hernia, and involves reduction of the hernia’s contents and elimination of the defect.     

Right paraduodenal hernia in childhood: a case report

A 7-year-old patient was recently treated surgically for a right paraduodenal hernia. Paraduodenal hernia is a rare cause of chronic abdominal complaints, as well as acute obstruction, and although it is not typical, it can manifest in childhood. The term "hernia" is a misnomer since this condition results from anomalous intestinal rotation. Knowledge of this embryology will prevent injury to vital mesenteric vessels during "repair" of a right paraduodenal hernia.     

Left paraduodenal hernia causing small bowel obstruction in an adolescent patient

Internal hernias are an uncommon cause of bowel obstruction, accounting for less than 1% of cases. Paraduodenal hernias, the most common type of internal hernias, are believed to be congenital in origin. They can be asymptomatic, cause chronic abdominal pain, or present with acute intestinal obstruction with strangulation and ischemia. We describe a case of left paraduodenal hernia found in a patient who presented with acute intestinal obstruction.     

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.     

Transmesocolic internal herniation: a rare case of small bowel obstruction, “the Marrakesh hernia”

Internal hernias, including paraduodenal (traditionally the most common), pericecal, foramen of Winslow, and intersigmoid hernias, account for approximately 0.5–5.8% of all cases of intestinal obstruction and are associated with a high mortality rate, exceeding 50% in some series. We report an extremely rare case of an internal abdominal hernia, through the right mesocolon, in a young woman with a right colon with no peritoneal fixation. This hernia was revealing by abdominal pain, nausea, and vomiting. The diagnosis of internal hernia was suggested by computed tomography (CT), but the exact type of internal hernia was confirmed by surgical exploration. The postoperative course was uneventful and the patient fully recovered after 3 days. The patient is free from symptoms and from recurrence, after 12 months of follow-up.     

Computed tomography diagnosis of symptomatic right paraduodenal hernia associated with enteric duplication cyst

Paraduodenal hernias rarely present with symptoms in children. We report a case of a right paraduodenal hernia associated with enteric duplication cyst that caused intestinal suboclussion in a 9-month-old female infant. Paraduodenal hernia was detected by contrast-enhanced computed tomography. In a review of the English-published literature, we have not found other reports of the association of paraduodenal hernia and enteric duplication cyst. A high index of suspicion is required for detecting paraduodenal hernias in children, and abdominal computed tomography is the most specific imaging study for their preoperative diagnosis.     

Mesenteric appendicitis strangulating small bowel: an exceptional internal herniation

Primitive internal hernias are a rare cause of intestinal obstruction. They are often paraduodenal even transmesocolic, but only rarely transomental. We present a rare case of an internal abdominal hernia in a young man. The small bowel was strangulated by an intra mesenteric appendicitis. This hernia was revealed by abdominal pain, nausea and vomiting. Plain X-ray of the abdomen showed dilated jejunal and ileal loops with multiple air-fluid levels. The diagnosis of appendicitis was suggested by ultrasound but the internal hernia was found only upon surgical exploration. An appendicectomy and adhesiolysis were performed. The patient recovered fully after 3 days, and had an uneventful postoperative course. The authors discuss the possible cause of this rare intestinal obstruction.     

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.     

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.     

Diagnostic laparoscopy and laparoscopic repair of a left paraduodenal hernia can shorten hospital stay.

Paraduodenal hernias are the most common forms of intraabdominal hernias, accounting for 53% of all internal hernias. However, these account for only 0.2% to 0.9% of all small intestinal obstructions overall. Patients usually report vague abdominal pains and discomfort lasting for many years. Furthermore, in-patient diagnosis and management can last up to several weeks due to its rarity and unusual presentation. We report a case of a left paraduodenal hernia in an 18-year-old male who presented with abrupt onset of abdominal pain, nausea, and vomiting. He was subsequently managed by diagnostic laparoscopy and laparoscopic repair, which decreased the overall in-patient care to 2 days.     

An interesting case of a left paraduodenal hernia with peritoneal encapsulation presenting as acute intestinal obstruction

Internal hernias commonly present as left duodenal, right duodenal, mesocolic, or retrocolic, intersigmoid hernias, as well as herniation through the foramen of Winslow and lesser sac herniation through an abnormal orifice [1]. Paraduodenal hernias are extremely rare entities, which may prove dangerous because of the high risk of bowel obstruction, strangulation and gangrene. These hernias are notorious because of non-specific signs and symptoms that can lead to diagnostic difficulties. We report the case of a left paraduodenal hernia with peritoneal encapsulation presenting as acute intestinal obstruction in a patient without any history of prior abdominal surgery. The patient underwent bowel reduction, adhesiolysis, resection of the sac, and repair of the defect. The patient’s recovery was uneventful.     

Laparoscopic repair of a paraduodenal hernia

Paraduodenal hernias have traditionally been treated by conventional laparotomy. We report the first case of a left paraduodenal hernia treated laparoscopically. A 44-year-old man was admitted with abdominal pain and nausea. Computed tomography and an upper gastrointestinal series with small-bowel followthrough showed accumulation of the small bowel on the left side of the abdomen. A laparoscopic repair was performed. The small bowel was observed beneath a thin hernia capsule. Approximately 1.5 m of jejunum was easily reduced into the abdominal cavity. The hernia orifice (5-cm diameter) was closed intracorporeally with five interrupted sutures. Good exposure of the operative field is critical to this procedure; poor exposure may limit the applicability of the laparoscopic approach. This minimally invasive operation is currently indicated in nonobstructive paraduodenal hernias, especially on the left. Received: 7 October 1996/Accepted: 11 April 1997     

Critical evaluation of a novel DualMesh repair for large hiatal hernias

Background  The use of mesh for laparoscopic repair of large hiatal hernias may reduce recurrence rates in comparison to primary suture repair. However, there is a potential risk of mesh-related oesophageal complications due to prosthesis erosion. The aim of this study was to critically evaluate a novel mesh (DualMesh) repair of hiatal hernias with particular reference to intraluminal erosion. Method  Medical records of 19 patients who underwent laparoscopic hiatal hernia repair with DualMesh reinforcement of the crural closure were reviewed from a prospectively collected database. Quality of life and symptom analysis was performed using quality of life in reflux and dyspepsia (QOLRAD) questionnaires pre- and postoperatively after 6 weeks, 6 months, 1 year and 2 years. Barium studies were performed on patients pre-operatively and two years postoperatively to assess hernia recurrence. After 2 years, oesophagogastric endoscopy was performed to assess signs of erosion. Results  Mean patient age was 70.5 years (range 49–85 years). Two years after hiatal hernia repair, there was significant improvement in quality-of-life scores (QOLRAD: p < 0.001). Follow-up barium studies performed at 31.3 months (range 29–40 months) after surgery showed moderate recurrent hernias (>4 cm) in 1/14 patients (7%). Endoscopies performed at 34.4 months (range 28–41 months) after surgery did not show any signs of prosthetic erosion. Conclusion  Laparoscopic reinforcement of primary hiatal closure with DualMesh leads to a durable repair in patients with large hiatal hernias. Long-term endoscopic follow-up did not show any signs of mesh erosion after prosthetic reinforcement of the crural repair.     

A case of a paraduodenal hernia

Paraduodenal hernias are rare hernias that result from error of rotation of the mid-gut. It can be discovered incidentally at laparotomy, seen on radiological imagining or infrequently cause intestinal obstruction. We report a case of a left paraduodenal hernia diagnosed intraoperatively after being operated on in the emergency setting for generalized peritonitis. He required resection of multiple loops of small bowel with primary anastomosis. The mouth of the sac was obliterated by suture apposition to the posterior wall. The patient was discharged on day 4 after an uneventful recovery.     

The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia repair in infected and potentially contaminated fields: long-term follow-up

Introduction  The treatment of hernias remains controversial, with multiple prosthetic meshes being exalted for a variety of their characteristics. In the event of incarcerated/strangulated hernias and other potentially contaminated fields the placement of prosthetic material remains controversial because of increased risk of recurrence and infection. Porcine small intestinal submucosa mesh (Surgisis, Cook Bloomington, IN) has been demonstrated safe and feasible in laparoscopic hernia repairs in this scenario. We present our 5-year experience, with placement of Surgisis mesh in potentially or grossly contaminated fields. Methods  From May 2000 to October 2006, 116 patients (52 male, 64 female) with 133 procedures were performed. Placement of Surgisis mesh for either incisional, umbilical, inguinal, femoral or parastomal hernia repairs in an infected or potentially contaminated setting were achieved, and studied in a prospective fashion. Results  All procedures were laparoscopically with two techniques [intraperitoneal onlay mesh (IPOM) and two-layered “sandwich” repair]. Mean follow-up was 52 ± 20.9 months. Thirty-nine cases were in an infected field and the rest in a potentially contaminated field. Ninety-one procedures were performed concurrently with a contaminated procedure. Twenty-five presented as intestinal obstruction, 16 strangulated hernias, and 17 required small bowel resection; 29 were inguinal hernias, 57 incisional, and 38 umbilical. In 13 patients more than two different hernias were repaired. Eighty-five percent 5-year follow-up was achieved, during which we identified 7 recurrences, 11 seromas (all resolved), and 10 patients reporting mild pain. Six second looks were performed and in all cases except one the mesh was found to be totally integrated into the tissue with strong scar tissue corroborated macro- and microscopically. Conclusions  In our experience the use of small intestine submucosa mesh in contaminated or potentially contaminated fields is a safe and feasible alternative to hernia repair with minimal recurrence rate and satisfactory results in long-term follow-up.     

Management of primary and recurrent inguinal hernia by surgeons from the South West of England

BACKGROUND: The National Institute of Clinical Excellence (NICE) has advocated open mesh repair for primary hernia but suggested laparoscopic repair may be considered for recurrent hernias. AIM: To establish current surgical practice by surgeons from the South West of England. METHODS: A postal survey was distributed to 121 consultant surgeons and a response rate of 75% was achieved. RESULTS: The majority (86%) of the surgeons surveyed performed hernia repairs, and most (95%) of these used open mesh repair as standard for primary inguinal hernia. Only 8% used laparoscopic repair routinely for primary hernias. Few consultants (only 28%) were able to quote formally audited hernia recurrence rates. A total of 90% of respondents still employed open mesh repair routinely for recurrent hernias; however, if mesh had been used for the primary repair, this figure fell to 55%. Some 7% of respondents recommended laparoscopic repair for recurrent hernia, but this increased to 17% if the primary repair was done with mesh. All laparoscopic surgeons in the South West employed the totally extraperitoneal approach (TEP). There was a range of opinion on the technical demands of repair of a recurrent hernia previously mended with mesh; the commonest cause of mesh failure was thought to be a medial direct recurrence (insufficient mesh medially). CONCLUSIONS: Current surgical practice for primary hernias in the South West England reflects NICE guidelines although many surgeons continue to manage recurrent hernias by further open repair. In this survey, there was anecdotal evidence to suggest that hernia recurrence can be managed effectively by open repair.     

Recurrent Spigelian hernia: a rare cause of colonic obstruction

Spigelian hernia is considered a surgical rarity. Recent articles describe only six recurrent hernias and a scant number of patients with colonic obstruction resulting from incarceration. A patient with intestinal obstruction resulting from recurrent Spigelian hernia with strangulated colon is described. The patient underwent tension-free repair using a prosthetic mesh. Recent literature suggests that the deficiency of connective tissue in patients with hernias justifies the widespread use of permanent mesh for tissue reinforcement and avoidance of recurrences. The rare case presented should be regarded as an illustrative example for application of the tension-free repair principle in the definitive management of recurrent Spigelian hernia. Electronic Publication     

Obturator hernia: clinical analysis of 16 cases and algorithm for its diagnosis and treatment

Background  Obturator hernia is an uncommon but important cause of intestinal obstruction. Methods  Retrospective study of 16 patients undergoing surgery for obturator hernia in a 20-year period. Results  All patients were elderly women. Low body mass index and multiparity were predisposing factors. Mean time from onset of symptoms to consultation was 4.1 days. The preoperative diagnosis was intestinal obstruction of unknown etiology in 13 cases and intestinal obstruction due to obturator hernia in three (diagnosis by CT). The rate of strangulated hernias was 75% and the perforation rate was 56.3%. Intestinal resection was required in 12 cases. Hernia repair was performed using polypropylene mesh in 11 cases and by means of simple suture and apposition of the peritoneum in five. Morbidity was 75% and mortality was 18.8%. Conclusions  Early diagnosis—we recommend CT in thin, elderly, multiparous women with intestinal obstruction—and early treatment can reduce complications and mortality.