Paraduodenal Hernia: Diagnosing and Treating a Rare Cause of Abdominal Pain

Understanding an Uncommon Surgical Challenge

Paraduodenal hernias represent one of the rarest forms of internal hernia, accounting for less than 1% of all intestinal obstructions. Yet, their potential for serious complications makes them an important condition for both patients and medical professionals to understand. A recent case at Burjeel Hospital Sharjah, managed by Dr. Mohamed Eraki, Consultant of General and Laparoscopic Surgery, highlights the challenges in diagnosing and treating this uncommon condition.

The Clinical Presentation: A Diagnostic Puzzle

The case involved a 33-year-old man who presented with a one-year history of intermittent symptoms including lethargy, tiredness, and occasional sharp generalized abdominal pain. Notably, the pain episodes typically lasted more than two hours before resolving, prompting multiple emergency room visits.

What made this case particularly challenging from a diagnostic standpoint was the absence of classic intestinal obstruction symptoms. The patient’s pain was not associated with nausea, vomiting, or weight loss—symptoms that would typically raise immediate concern for intestinal disorders.

The Diagnostic Journey

Given the persistent nature of the symptoms, a CT scan of the abdomen with contrast was performed, revealing a critical finding: jejunal loops concentrated along the left paraduodenal region with mild prominence of the lumen (maximum diameter of 2.5 cm).

The CT scan showed:

• Normal caliber of small bowel loops following the dilated section
• No obvious air-fluid levels within the small bowel loops
• No free fluid around the small bowel loops
• No appreciable membranes noted around the small bowel loops
• Normal appearance of the remaining visualized bowel loops

Based on these findings, a diagnosis of left-side paraduodenal hernia was established.

Understanding Paraduodenal Hernias

Paraduodenal hernias occur when intestinal loops protrude through a peritoneal defect near the duodenum. Left-sided paraduodenal hernias, as seen in this case, are more common than right-sided ones, accounting for approximately 75% of all paraduodenal hernias.

These hernias develop during embryonic rotation of the midgut and abnormal fixation of the mesentery. The hernial sac typically contains small bowel loops, and in left-sided cases, the inferior mesenteric vein often forms part of the anterior border of the hernial sac, creating a potential vascular complication during surgery.

Surgical Management: The Laparoscopic Approach

To address this rare condition, Dr. Eraki performed a laparoscopic abdominal exploration, which revealed:

• Most of the small bowel collected in one sac, with a membrane to the left of the duodenum
• The terminal ileum emerging from beneath a peritoneal fold, possibly containing the inferior mesenteric vein
• Partial obstruction of the small bowel by the inferior mesenteric vein crossing the terminal ileum

The surgical management involved several critical steps:

1. Opening the peritoneal sac to reveal the small bowel
2. Carefully reducing the entire small bowel from beneath the vascular fold
3. Closing the defect between the inferior mesenteric vein and posterior abdominal wall with a continuous absorbable suture
4. Excising and plicating the peritoneal sac

Surgical Challenges and Considerations

Dr. Eraki noted two primary challenges in managing this case:

1. Accurate diagnosis – The nonspecific symptoms made initial diagnosis difficult
2. Preservation of the inferior mesenteric vein – Maintaining vascular integrity while performing hernia repair required careful surgical technique
3. Defect closure – The size and location of the defect presented technical challenges for secure closure

Clinical Significance and Learning Points

This case highlights several important clinical lessons:

1. High index of suspicion – Paraduodenal hernias should be considered in the differential diagnosis of patients with recurrent, intermittent abdominal pain, especially when symptoms are atypical.
2. Value of CT imaging – Contrast-enhanced CT scans play a crucial role in the preoperative diagnosis of internal hernias.
3. Laparoscopic management – The laparoscopic approach offers both diagnostic and therapeutic benefits, allowing for detailed visualization and definitive management with minimal invasiveness.
4. Anatomical awareness – Understanding the vascular relationships, particularly the position of the inferior mesenteric vein, is essential for safe surgical repair.

Long-term Outcomes and Prognosis

Following successful laparoscopic repair, patients with paraduodenal hernias typically experience complete resolution of symptoms and have an excellent prognosis. Early diagnosis and intervention are crucial to prevent potential complications such as bowel obstruction, strangulation, and ischemia, which can significantly increase morbidity and mortality.

For patients experiencing unexplained, recurrent abdominal pain, this case serves as a reminder of the importance of pursuing a comprehensive diagnostic evaluation and considering uncommon etiologies when symptoms persist despite normal initial assessments.

Conclusion

Paraduodenal hernias, while rare, represent an important and treatable cause of recurrent abdominal pain. This case from Burjeel Hospital Sharjah demonstrates the value of advanced imaging, surgical expertise, and a minimally invasive approach in managing this uncommon condition. For clinicians, maintaining awareness of such rare entities can make the difference between prolonged symptoms and definitive treatment.

Experts