Giant left paraduodenal hernia

Abstract

SUMMARYLeft paraduodenal hernia (LPDH) is a retrocolic internal hernia of congenital origin that develops through the fossa of Landzert, and extends into the descending mesocolon and left portion of the transverse mesocolon. It carries significant overall risk of mortality, yet delay in diagnosis is not unusual due to subtle and elusive features. Familiarisation with the embryological and anatomical features of this rare hernia is essential for surgical management. This is especially important with respect to vascular anatomy as major mesenteric vessels form intimate relationships with the ventral rim and anterior portion of the hernia. As an illustrative case, we describe our experience with a striking example of LPDH, particularly focusing on the inherent diagnostic challenges and associated critical vascular anatomy. We advocate the role of diagnostic laparoscopy; however caution that decision to safely proceed with laparoscopic repair must occur only with confident identification of the vascular anatomy involved. BACKGROUND

Paraduodenal hernias in children: Etiology, treatment, and outcomes of a rare but real cause of bowel obstruction

“…The fossa of Landzert is located lateral to the fourth part of the duodenum, posterior to the inferior mesenteric vein (IMV) and the ascending branch of the ascending left colic artery (LCA), directly beneath the posterior parietal peritoneum. Most authors believe that LPDH result from the malrotation of the midgut, by invagination of the small bowel into the avascular segment of the left mesocolon that therefore fails to fuse with the posterior parietal peritoneum [10]. Still, some authors believe that primitive fusion failure of the left mesocolon results in a congenital fossa, where the small bowel herniates later on [9].…”

“…Almost half of the PDH patients are asymptomatic and the other half can present with recurrent upper abdominal pain (43%) [6], symptoms of partial or complete small bowel obstruction or mesenteric vascular compromise [10]. However, 69% of the symptomatic cases present with chronic symptoms of around 1.8 years duration preceding the obstruction or strangulation symptoms.…”

Remember the internal hernia: laparoscopic repair of left‐sided paraduodenal hernia causing acute small bowel obstruction

“…Internal hernias are a rare cause of bowel obstruction, being the aetiology for <1% of cases but should be suspected in the patient without previous abdominal surgery . The paraduodenal fossa, also known as Landzert's fossa, is the space lateral to the fourth part of the duodenum and posterior to the inferior mesenteric vein (IMV) and the ascending left colic artery whereby bowel can herniate (Fig. ).…”

“…). Most authors agree that this defect is a congenital malrotation of the midgut with the failure of fusion between the posterior peritoneum and intestinal mesentery …”

“…Definitive repair requires reduction of the hernia content and either direct closure or widening of the hernia orifice, the latter of which was performed in our patient. The critical step is identification and dissection of the IMV and left colic artery vessels.…”