Laparoscopic repair of left paraduodenal hernia
A 35-year-old male presented to accident and emergency with left upper abdominal pain, nausea and loss of appetite for 3 days. On retrospective questioning, he admitted to a propensity to vomit occasionally after large meals dating back to his childhood. On examination his abdomen was mildly distended with tenderness and a mass in his left upper quadrant. Chest and abdominal X-ray were normal. CT scan of the abdomen and pelvis with oral and i.v. contrast showed a left paraduodenal hernia (Fig. ). Within 24 h his symptoms had resolved spontaneously and he was able to eat freely without pain and was discharged. He had mild left upper quadrant pain on a few occasions over the next 2 weeks and the option of surgical repair was discussed. As 50% or more paraduodenal hernias develop partial or complete small intestinal obstruction, surgical treatment was recommended. The patient decided to proceed to surgical treatment and a minimal access approach was planned.\nHasson's insufflations technique was used for an initial infra-umbilical port insertion. Two further operating ports were place in the right lower quadrant under direct vision. Laparoscopy confirmed the radiological findings; the majority of the small intestine was found to lie inside the paraduodenal hernial sac. The sac lay behind the mesentery of the descending colon extending cranially behind the transverse colon and splenic flexure and lesser sac in front of the structures of the left retro-peritoneum. The neck of the hernia neck was formed anteriorly by free edge of descending colonic mesentery containing inferior mesenteric vein and posteriorly by retro-peritoneum. The neck lay to the left and caudal to the duodeno-jejunal junction with the ligament of Treitz fusing with the superior boarder. The proximal Jejunum directly distal to the DJ flexure entered the sac, the terminal ileum was identified within the abdomen, the caecum lay in the right iliac fossa, the remainder of the small intestine was within the hernia (Fig. 1 and 2). There were peritoneal adhesions at the neck of the hernia to the viscera entering the sac which prevented spontaneous reduction. Operative reduction of the hernia commenced with sharp dissection of these adhesions, followed by sharp and blunt dissection, the neck of the sac was cleared and mobilized. Once this procedure was complete the small intestine was easily reduced to the abdominal cavity, occasional adhesions to the hernial sac were divided to complete this process (Fig. 3 and 4). The hernial neck was closed with a continuous suture opposing the peritoneum of the free boarder of the descending colonic mesentery to the peritoneum below the D-J flexure to the left of the aorta. Post-operative recovery was uncomplicated and discharge was within 23 h. The patient made good recovery and to date has had no recurrence of symptoms over 3 years of follow-up.