Para-duodenal hernia: a report of five cases and review of literature

Para-duodenal hernias (PDH) have traditionally been considered the most frequent type of congenital internal hernia [1]. Left para-duodenal hernia (hernia of Lanzert) is about three times more common than the right counterpart (Waldayer’s hernia) [2]. Left para-duodenal hernia (LPDH) is a congenital defect with an occurrence of approximately 2% of the population. It is posterior to the inferior mesenteric vein and left branches of middle colic artery and is situated to the left of the fourth part of the duodenum. It arises from the fossa of Landzert [3‐5]. The fossa to the left of the fourth part of the duodenum is the area where the small bowel loops (usually jejunum) prolapse through and into the left portion of the transverse mesocolon. The herniated small bowel loops may therefore become trapped within the mesenteric sac [5, 6]. The initial rotation of the midgut behind and then left to the superior mesenteric artery and comes to lie in the left side of the abdomen behind the mesentery of the descending colon leads to development of LPDH [7]. The right para-duodenal hernia (RPDH) occurs when the small bowel herniates through a defect in the first part of the jejunal mesentery in the so called Waldeyer’s fossa. At autopsy, the Waldeyer’s fossa was found in about 1% of the population [8]. The malrotation of the midgut and failure of fusion of mesentery to parietal peritoneum create a hernial defect called RPDH. PDH can lead to bowel obstruction, ischemia, and perforation with a high mortality [6]. Clinical diagnosis of PDH is a challenge as symptoms are entirely non-specific. They usually affect males more than females (3:1) [9, 10]. Most patients are diagnosed between the 4th and 6th decades of life and the mean age of diagnosis is 38.5 years [2]; for our case series all were males. 75% of mesocolic hernias occur on the left side and 25% on the right side with middle mesocolic hernia being very rare [11]. In medical literature, para-duodenal hernias causing intestinal obstruction are few and report no evidence of long lasting postoperative ileus after surgery. We report herein five cases of PDH and their management based on a review of literatures.

PDH also known as mesocolic hernias are congenital and derive from embryonary peritoneal anomalies and associated abnormal intestinal rotation [12]. These patients usually present with chronic abdominal pain and vomiting with or without signs of intestinal obstruction [9]. There is an associated risk of strangulation and intestinal infarction for more than 50% over the course of a lifetime, making it necessary to investigate radiological signs of hypoperfusion and intestinal ischemia [13]. The high rate of mortality associated with these complications make early identification indispensable and justifies the role of abdominal CT in the early pre-operative diagnosis of paraduodenal hernia. Multislice computer tomography (CT) offers high resolution and multiplanar images which may be very demonstrative and characteristic providing a precise and early diagnosis, useful for surgical treatment planning [6, 12]. In typical CT images, PDH shows a cluster of dilated bowel segments with engorged and displaced mesenteric vessels at the hernial orifice [14]. Early surgical intervention is essential to avoid future complications because patients with PDH have a 20–50% mortality for acute presentations [15, 16]. A literature search was performed to identify the rare cases of paraduodenal hernia treated with laparoscopic approach. Only 28 case reports were published between January 1998, in which Uernatsu et al. [17]. first described the minimally invasive treatment of this surgical emergency, and November 2015. The several advantages of laparoscopic approach, deduced after analysing data in previous cases, were: decrease in post-operative pain, reduced morbidity, early food resumption (1.33 average, 1–3), shorter hospital stay (3.60 average, range 1–10). These benefits occurred regardless of type of intervention (elective or emergency), type of repair (closure of hernial defect with continuous or interrupted suture, enlargement of defect or resection of the sac) and type of material used (adsorbable or not adsorbable, monofilament or poly-filament) [9, 10, 17‐35]. We opted for laparoscopic approach for all our five patients who shared same benefits as described by other authors.

Therefore, based on our experience and current literatures, we believe that laparoscopic approach is the optimum treatment strategy for patients with paraduodenal hernia, especially in health centres with strong experience of advanced laparoscopic surgery. Patients with or without small bowel obstruction and hemodynamically stable are suitable to enjoy the benefits of laparoscopic approach. Computed tomography remains the gold standard of imaging modality for early diagnosis of this clinical entity. However, the limitation of our report is that the number of cases is small and hence, a concrete conclusion can only be drawn based on our experience so far.