A Left Paraduodenal Hernia: an "Incidental Finding" in a Virgin Abdomen with Small Bowel Obstruction

A left paraduodenal hernia is a rare clinical condition, resulting from embryological abnormalities or anomalies of the peritoneal attachments. Preoperative diagnosis is difficult because of its nonspecific clinical manifestations.

A 42-year-old man, with negative surgical history, presented to the emergency department with complaints of severe acute epigastric pain and vomiting of 12 h duration. The patient did not report any episodes of abdominal pain in his history. Computed tomography imaging was suggestive for a closed-loop obstruction. An emergency laparoscopy was performed, revealing a pathologically dilated tangle of jejunal loops and an incidental finding of a left paraduodenal hernia, the latter containing small bowel loops with normal caliber. The small bowel loops were reduced, and the hernia orifice was closed via non-absorbable sutures to restore normal anatomy. The pathologically dilated small bowel segment with serosal scar tissue, probably developed secondary to a previous episode of incarceration, was resected.

A high level of clinical suspicion for a left paraduodenal hernia is advocated in patients with a virgin abdomen, presenting with recurrent vague abdominal pain or acute symptoms of small bowel obstruction. Usually, a left paraduodenal hernia is an incidental finding on computed tomography imaging or during diagnostic laparoscopy. Surgical repair is the mainstay therapy, even in asymptomatic cases, to prevent future small bowel incarceration which develops in almost half of the cases. The laparoscopic approach is feasible and safe, also in an emergency setting.

By presenting this case, we assume to raise awareness as many clinicians are unfamiliar with this rare condition. Clinical suspicion and detailed knowledge of the etiology, anatomy, and vascular landmarks allow surgeons to accurately manage a left paraduodenal hernia.