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Strangulated Paraduodenal Hernia
Symposium on Surgical Techniques
Strangulated Paraduodenal Hernia Report of a Case
Horst Filtzer, M.D., and Cornelius E. Sedgwick, M.D.
Internal hernia as a cause for acute intestinal obstruction is quite rare. Many such hernias are found incidentally at laparotomy or autopsy. Twenty of 61 cases reported by Andrews! were discovered in this manner, while 3 of the 5 patients reported by Bartlett et al. 2 had no symptoms. The following case is reported because of its unusual clinical manifestations and typical radiologic appearance.
CASE REPORT A 49 year old man was admitted to the Boston City Hospital on May 24, 1971, with severe abdominal pains. Ten hours before admission, colicky periumbilical pain developed. This localized in the right lower quadrant after 8 hours. The pain became steady and sharp. The patient vomited bilious fluid several times but had no hematemesis or melena. Right inguinal hernia and its recurrence had been repaired in 1949 and 1953. Physical examination revealed a well-developed, well-nourished man in acute distress. Blood pressure was 130 mm. Hg systolic and 90 mm. Hg diastolic, pulse was 88 beats per minute, and respirations were 18. The abdomen was minimally distended, no organs or masses were palpable, and no hernias were noted. Right lower quadrant tenderness, guarding, and rebound tenderness were noted. The psoas sign was positive; bowel sounds were absent. Rectal examination showed no tenderness or masses. Laboratory data revealed white blood cell count, 12,300 per cu. mm.; hematocrit, 45; and serum amylase, 95 units per 100 ml. The urinalysis was normal. A chest roentgenogram was within normal limits. Roentgenograms of the kidney, ureter, and bladder, and roentgenogram with the patient in an upright position demonstrated dilated loops of small bowel in the right upper quadrant (Fig. 1). Surgical Clinics of North America- Vol. 53, No.2, April 1973
371
372
Figure 1.
HORST FILTZER AND CORNELIUS
E.
SEDGWICK
Plain film of abdomen showing distended small bowel of right upper quadrant.
Figure 2. Appearance of strangulated bowel at the time of operation.
STRANGULATED PARADUODENAL HERNIA
373
Following nasogastric intubation and hydration with Ringer's lactate solution, 1500 mI., an exploratory operation was performed through a generous right paramedian incision. After the abdomen was opened, a large amount of bloody fluid was aspirated from the right paracolic gutter. Three loops of distended, erythematous, but viable small bowel were noted to be emerging from a hernial ring that also contained the ileocecal valve and proximal jejunum just beyond the ligament of Treitz. The remainder of the small bowel was contained in a hernial sac, the apex of which pointed downward and to the left. The inferior mesenteric vessels formed the margin of the hernial ring and were attenuated (Fig. 2). Reduction of the hernia was effected by transection of the inferior mesenteric vessels between clamps and excision of all excess hernial sac, sparing the left colic vessels. The abdomen was closed in layers. Postoperatively the patient did well, except for ileus, and was discharged on the eleventh postoperative day.
COMMENT
This patient had a typical left paraduodenal hernia with symptoms referable to the right lower quadrant because bloody fluid accumulated in the right paracolic gutter. It would seem that as long as the small bowel remained in the sac no symptoms were produced. Strangulation occurred when loops of small bowel left the hernial sac and became incarcerated outside the tight hernial ring. Andrews,! in 1923, pointed out that invagination of small bowel into any of the named duodenal fossae seemed an unlikely mechanism for the formation of paraduodenal hernia. Since in 90 per cent of his 60 cases more than one half of the small bowel was contained in the hernial sac, he proposed that an anomaly of the development of the peritoneum was most likely. He concluded that paraduodenal hernia was the result of imprisonment of small bowel beneath the mesentery of the developing colon. Callander et al. 3 agreed that the developing small bowel invaginates beneath the mesentery of the descending colon, producing a hernia which they called a left duodenal hernia. Zimmerman and Laufman 5 noted that paraduodenal hernia was the commonest of the internal hernias. At the end of the tenth week of intra-uterine life, the umbilical loop of bowel returns to the abdominal cavity, rotating an additional 180° in a counterclockwise direction. The proximal position usually returns first and passes beneath the superior mesenteric artery. The cecum and ascending colon are reduced last and come to lie in the right upper quadrant. Thus the superior mesenteric vessels act as the axis of rotation of the midgut. A right paraduodenal hernia is produced when the umbilical loop fails to rotate completely and is caught beneath the cecum as it rotates from the left to the right. The right colon fuses with the parietal peritoneum, and the small bowel becomes imprisoned behind its mesentery. The superior mesenteric and ileocolic arteries then lie in the free edge of
374
HORST FILTZER AND CORNELIUS
E.
SEDGWICK
the sac, and its apex points upward and to the right. A left paraduodenal hernia is produced by reverse rotation of the umbilical loop. As the small bowel is reduced into the abdominal cavity, it is caught beneath the mesentery of the descending colon, leaving the free edge of the sac to contain the inferior mesenteric and left colic vessels with the apex pointing downward and to the left. The formation of these hernias is reviewed by Wang and Welch. 4 The surgical correction of a left paraduodenal hernia consists of transection of the inferior mesenteric vessels to release the ring and to permit reduction of the small bowel content. A right paraduodenal hernia, according to Bartlett et al.," is treated by reflection of the right colon medially, opening the sac to reduce the small bowel, and, in effect, producing nonrotation of the small bowel.
SUMMARY Incarceration of paraduodenal hernia as a cause for intestinal obstruction is quite rare. Left paraduodenal hernia arises as a result of anomalous rotation of the midgut into the developing mesentery of the descending colon. Right paraduodenal hernias are the result of entrapment of the small bowel by the developing cecum as it rotates from left to right. Surgical correction of these anomalies depends upon the resection of the hernial ring containing the inferior mesenteric vessels for a left paraduodenal hernia A right paraduodenal hernia is corrected by reflection of the right colon to the left and release of the entrapped small bowel, producing a nonrotation of the bowel.
REFERENCES 1. Andrews, E.: Duodenal hernia-a misnomer. Surg. Gynec. Obstet. 37:740-750 (Dec.) 1923. 2. Bartlett, M.K., Wang, C., and Williams, W.H.: The surgical management of paraduodenal hernia. Ann. Surg. 168:249-254 (Aug.) 1968. 3. Callander, C.L., Rusk, G.Y., and Nemir, A.: Mechanism, symptoms, and treatment of hernia into descending mesocolon (left duodenal hernia); plea for change in nomenclature. Surg. Gynec. Obstet. 60:1052-1071 (June) 1935. 4. Wang, C.A., and WeIch, C.E.: Anomalies of intestinal rotation in adolescents and adults. Surgery 54:839-855 (Dec.) 1963. 5. Zimmerman, L.M., and Laufman, H.: Intra-abdominal hernias due to developmental and rotational anomalies. Ann. Surg. 138:82-91 (July) 1953. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215
Strangulated Paraduodenal Hernia Report of a Case
Horst Filtzer, M.D., and Cornelius E. Sedgwick, M.D.
Internal hernia as a cause for acute intestinal obstruction is quite rare. Many such hernias are found incidentally at laparotomy or autopsy. Twenty of 61 cases reported by Andrews! were discovered in this manner, while 3 of the 5 patients reported by Bartlett et al. 2 had no symptoms. The following case is reported because of its unusual clinical manifestations and typical radiologic appearance.
CASE REPORT A 49 year old man was admitted to the Boston City Hospital on May 24, 1971, with severe abdominal pains. Ten hours before admission, colicky periumbilical pain developed. This localized in the right lower quadrant after 8 hours. The pain became steady and sharp. The patient vomited bilious fluid several times but had no hematemesis or melena. Right inguinal hernia and its recurrence had been repaired in 1949 and 1953. Physical examination revealed a well-developed, well-nourished man in acute distress. Blood pressure was 130 mm. Hg systolic and 90 mm. Hg diastolic, pulse was 88 beats per minute, and respirations were 18. The abdomen was minimally distended, no organs or masses were palpable, and no hernias were noted. Right lower quadrant tenderness, guarding, and rebound tenderness were noted. The psoas sign was positive; bowel sounds were absent. Rectal examination showed no tenderness or masses. Laboratory data revealed white blood cell count, 12,300 per cu. mm.; hematocrit, 45; and serum amylase, 95 units per 100 ml. The urinalysis was normal. A chest roentgenogram was within normal limits. Roentgenograms of the kidney, ureter, and bladder, and roentgenogram with the patient in an upright position demonstrated dilated loops of small bowel in the right upper quadrant (Fig. 1). Surgical Clinics of North America- Vol. 53, No.2, April 1973
371
372
Figure 1.
HORST FILTZER AND CORNELIUS
E.
SEDGWICK
Plain film of abdomen showing distended small bowel of right upper quadrant.
Figure 2. Appearance of strangulated bowel at the time of operation.
STRANGULATED PARADUODENAL HERNIA
373
Following nasogastric intubation and hydration with Ringer's lactate solution, 1500 mI., an exploratory operation was performed through a generous right paramedian incision. After the abdomen was opened, a large amount of bloody fluid was aspirated from the right paracolic gutter. Three loops of distended, erythematous, but viable small bowel were noted to be emerging from a hernial ring that also contained the ileocecal valve and proximal jejunum just beyond the ligament of Treitz. The remainder of the small bowel was contained in a hernial sac, the apex of which pointed downward and to the left. The inferior mesenteric vessels formed the margin of the hernial ring and were attenuated (Fig. 2). Reduction of the hernia was effected by transection of the inferior mesenteric vessels between clamps and excision of all excess hernial sac, sparing the left colic vessels. The abdomen was closed in layers. Postoperatively the patient did well, except for ileus, and was discharged on the eleventh postoperative day.
COMMENT
This patient had a typical left paraduodenal hernia with symptoms referable to the right lower quadrant because bloody fluid accumulated in the right paracolic gutter. It would seem that as long as the small bowel remained in the sac no symptoms were produced. Strangulation occurred when loops of small bowel left the hernial sac and became incarcerated outside the tight hernial ring. Andrews,! in 1923, pointed out that invagination of small bowel into any of the named duodenal fossae seemed an unlikely mechanism for the formation of paraduodenal hernia. Since in 90 per cent of his 60 cases more than one half of the small bowel was contained in the hernial sac, he proposed that an anomaly of the development of the peritoneum was most likely. He concluded that paraduodenal hernia was the result of imprisonment of small bowel beneath the mesentery of the developing colon. Callander et al. 3 agreed that the developing small bowel invaginates beneath the mesentery of the descending colon, producing a hernia which they called a left duodenal hernia. Zimmerman and Laufman 5 noted that paraduodenal hernia was the commonest of the internal hernias. At the end of the tenth week of intra-uterine life, the umbilical loop of bowel returns to the abdominal cavity, rotating an additional 180° in a counterclockwise direction. The proximal position usually returns first and passes beneath the superior mesenteric artery. The cecum and ascending colon are reduced last and come to lie in the right upper quadrant. Thus the superior mesenteric vessels act as the axis of rotation of the midgut. A right paraduodenal hernia is produced when the umbilical loop fails to rotate completely and is caught beneath the cecum as it rotates from the left to the right. The right colon fuses with the parietal peritoneum, and the small bowel becomes imprisoned behind its mesentery. The superior mesenteric and ileocolic arteries then lie in the free edge of
374
HORST FILTZER AND CORNELIUS
E.
SEDGWICK
the sac, and its apex points upward and to the right. A left paraduodenal hernia is produced by reverse rotation of the umbilical loop. As the small bowel is reduced into the abdominal cavity, it is caught beneath the mesentery of the descending colon, leaving the free edge of the sac to contain the inferior mesenteric and left colic vessels with the apex pointing downward and to the left. The formation of these hernias is reviewed by Wang and Welch. 4 The surgical correction of a left paraduodenal hernia consists of transection of the inferior mesenteric vessels to release the ring and to permit reduction of the small bowel content. A right paraduodenal hernia, according to Bartlett et al.," is treated by reflection of the right colon medially, opening the sac to reduce the small bowel, and, in effect, producing nonrotation of the small bowel.
SUMMARY Incarceration of paraduodenal hernia as a cause for intestinal obstruction is quite rare. Left paraduodenal hernia arises as a result of anomalous rotation of the midgut into the developing mesentery of the descending colon. Right paraduodenal hernias are the result of entrapment of the small bowel by the developing cecum as it rotates from left to right. Surgical correction of these anomalies depends upon the resection of the hernial ring containing the inferior mesenteric vessels for a left paraduodenal hernia A right paraduodenal hernia is corrected by reflection of the right colon to the left and release of the entrapped small bowel, producing a nonrotation of the bowel.
REFERENCES 1. Andrews, E.: Duodenal hernia-a misnomer. Surg. Gynec. Obstet. 37:740-750 (Dec.) 1923. 2. Bartlett, M.K., Wang, C., and Williams, W.H.: The surgical management of paraduodenal hernia. Ann. Surg. 168:249-254 (Aug.) 1968. 3. Callander, C.L., Rusk, G.Y., and Nemir, A.: Mechanism, symptoms, and treatment of hernia into descending mesocolon (left duodenal hernia); plea for change in nomenclature. Surg. Gynec. Obstet. 60:1052-1071 (June) 1935. 4. Wang, C.A., and WeIch, C.E.: Anomalies of intestinal rotation in adolescents and adults. Surgery 54:839-855 (Dec.) 1963. 5. Zimmerman, L.M., and Laufman, H.: Intra-abdominal hernias due to developmental and rotational anomalies. Ann. Surg. 138:82-91 (July) 1953. Lahey Clinic Foundation 605 Commonwealth Avenue Boston, Massachusetts 02215