Background: Para-duodenal hernia (PDH) represents rare clinical entities based on few literatures. Case presentation: We report five cases of Para-duodenal hernia, all occurring in male patients ranging from 34 to 75 years of age. The patients had varied manifestations presenting with abdominal pain with or without vomiting and nausea and with or without signs of intestinal obstruction. CT images showed cluster of dilated bowel segments with displaced mesenteric vessels at hernial orifice. Laparoscopic surgical approach was adopted, and the patients were discharged about a week later without further complications. Conclusion: We hope to raise awareness about the management of this rare clinical entity and the benefits of CT imaging and laparoscopic surgery as standard approaches. Keywords: Paraduodenal hernia, Intestinal obstruction, Abdominal pain, CT images, Laparoscopic surgery Background comes to lie in the left side of the abdomen behind the Para-duodenal hernias (PDH) have traditionally been mesentery of the descending colon leads to development considered the most frequent type of congenital internal of LPDH . The right para-duodenal hernia (RPDH) hernia . Left para-duodenal hernia (hernia of Lanzert) occurs when the small bowel herniates through a defect is about three times more common than the right coun- in the first part of the jejunal mesentery in the so called terpart (Waldayer’s hernia) . Left para-duodenal her- Waldeyer’s fossa. At autopsy, the Waldeyer’sfossa was nia (LPDH) is a congenital defect with an occurrence of found in about 1% of the population . The malro- approximately 2% of the population. It is posterior to tation of the midgut and failure of fusion of mesen- the inferior mesenteric vein and left branches of middle tery to parietal peritoneum create a hernial defect colic artery and is situated to the left of the fourth part called RPDH. PDH can lead to bowel obstruction, is- of the duodenum. It arises from the fossa of Landzert chemia, and perforation with a high mortality . [3–5]. The fossa to the left of the fourth part of the duo- Clinical diagnosis of PDH is a challenge as symptoms denum is the area where the small bowel loops (usually are entirely non-specific. They usually affect males jejunum) prolapse through and into the left portion of more than females (3:1) [9, 10]. Most patients are di- the transverse mesocolon. The herniated small bowel agnosed between the 4th and 6th decades of life and loops may therefore become trapped within the mesen- the mean age of diagnosis is 38.5 years ; for our teric sac [5, 6]. The initial rotation of the midgut behind case series all were males. 75% of mesocolic hernias and then left to the superior mesenteric artery and occur on the left side and 25% on the right side with middle mesocolic hernia being very rare . In med- ical literature, para-duodenal hernias causing intestinal * Correspondence: firstname.lastname@example.org † obstruction are few and report no evidence of long Kamleshsingh Shadhu and Dadhija Ramlagun contributed equally to this work. lasting postoperative ileus after surgery. We report Department of General Surgery, Jiangsu Province Hospital, First Affiliated herein five cases of PDH and their management based hospital of Nanjing Medical University, Guangzhou Road, 300, Gulou District, on a review of literatures. Nanjing 210029, Jiangsu Province, People’s Republic of China Department of Gastric Surgery, Jiangsu Province Hospital, First Affiliated hospital of Nanjing Medical University, Guangzhou Road, 300, Gulou District, Nanjing 210029, Jiangsu Province, People’s Republic of China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Shadhu et al. BMC Surgery (2018) 18:32 Page 2 of 7 Case presentation Case 1 A 68-year-old man complained left middle abdominal pain for 10 days. The pain was paroxysmal without nau- sea and vomiting. It got worse after meals. He has a past medical history of chronic gastritis treated with regular proton pump inhibitor. He had laparoscopic cholecyst- ectomy 2 years ago. The results of complete blood count, serum and urine amylase were within normal limit. Endoscopy showed chronic gastritis with bile re- flux. His abdominal CT scan showed that a part of small intestine and its mesentery were folded together on the left side of the abdomen (Fig. 1). The patient was diag- Fig. 2 The defect in the transverse mesocolon. M: transverse mesocolon, nosed with abdominal internal hernia and laparoscopic D: the ascending part of duodenum, HO: hernia orifice surgery was done. During the surgery, a soft mass of 5 cm in diameter was found within the transverse meso- colon. It was later found to be that 60 cm of the small intestine, the hernia orifice was opened large enough to intestine, which was trapped through a defect in the prevent further herniation (Fig. 4). Post-operative recovery transverse mesocolon. The defect was 2 cm in diameter was uneventful, and the patient was discharged on 7th on the left side of the ascending part of duodenum post-operative day. No abnormalities were found during (Fig. 2) within the mesocolon. The entrapped intestinal follow-up so far. (Table 1). loop was reduced, and the defect was repaired. He was diagnosed with left paraduodenal hernia and was dis- Case 3 charged on 7th post-operative day. No abnormal presen- A 68-year-old man complained about upper abdominal tation was found during follow-up. (Table 1). pain for 2 days. The pain was paroxysmal accompanied with vomiting. He was diagnosed with chronic gastritis Case 2 2 months ago and was treated with medications without A 34-year-old man complained about left upper abdom- any relief. His abdominal CT imaging showed part of inal pain for 24 h. The pain was paroxysmal accompanied the small intestine was folded (Figs. 5, 6). He underwent with vomiting. His abdominal CT scan showed a fold, at paraduodenal hernioplasty via laparoscopy. Surgery con- the left upper abdomen, consisting of small intestine sisted of reduction of intestinal loops in the hernial sac coiled with mesentery (Fig. 3). Subsequent laparoscopy and subsequent repair of the defect (Fig. 7). The length found a loop of jejunum was entrapped in the left side of of the folded intestine was found to be 100 cm and the mesocolon through a defect on the left side of the ascend- hernia was on the left side of mesocolon. He was dis- ing part of duodenum. After the reduction of the small charged on 7th post-operative day and had no complica- tions during follow-up so far. (Table 1). Case 4 A 75-year-old man complained about abdominal disten- tion and pain for 13 h. The pain was paraumbilical ac- companied with nausea and vomiting. His abdominal CT imaging showed that the jejunum was folded at the left abdomen (Figs. 8, 9). He was diagnosed with left paraduodenal hernia and laparoscopy was carried out. During the surgery, reduction of the entrapped jejunal loops from the hernial sac was attempted but failed due to severe adhesion with surrounding organs. It was then converted to open enterolysis. The defect of the mesoco- lon was found on the right side of the ascending duode- num and was repaired eventually with interrupted Fig. 1 Transverse view of CT image showing the cluster of small sutures (Fig. 10). After the surgery, the patient still felt intestine and its mesentery. The entrapped intestinal loop was occasional distension after meals, but no acute episode behind the infernal mesenteric vein (white arrow) of obstruction has ever occurred. He was discharged two Shadhu et al. BMC Surgery (2018) 18:32 Page 3 of 7 Table 1 Summary of five cases of paraduodenal hernia Cases 1 2 3 4 5 Features Age (years old) 68 34 68 75 40 Gender Male Male Male Male Male Imaging modality CT CT CT CT X-ray, CT Radiological signs CT scan showed a CT scan showed a CT scan showed CT scan showed X-ray showed a mass part of small intestine fold at the left upper part of small jejunum was at right upper abdominal and its mesentery abdomen, consisting intestine was folded at the left quadrant. CT scan showed folded together at the of small intestine folded. abdomen. a part of small intestine left abdomen. coiled with mesentery. and its mesentery were folded together at the right abdomen. Location of hernia Left Left Left Left Right Presenting symptoms Left middle abdominal Left upper abdominal Upper abdominal Paraumbilical pain Right abdominal pain for paroxysmal pain for paroxysmal pain for paroxysmal pain and abdominal 11 h with sudden onset. 10 days without nausea 24 h with vomiting. for 2 days with distention with and vomiting. vomiting. nausea and vomiting for 13 h. Type of surgery Laparoscopy Laparoscopy Laparoscopy Laparoscopy Laparoscopy turned into open th Discharge (n POD) 7 7 7 14 9 Complications during None None None None None follow-up weeks later, and he had no complications during together at the right abdomen (Figs. 12, 13). A diagnosis follow-up so far. (Table 1). of right paraduodenal hernia was made. The patient underwent laparoscopic surgery during which the en- Case 5 trapped intestinal loop was reduced from a defect in the A 40-year-old man complained about right abdominal first part of the jejunal mesentery. He was discharged on pain for 11 h. The pain occurred suddenly without trig- 9th post-operative day. No other abnormal presentation gering factors. It was mild and intermittent. He has a was found during follow-up so far. (Table 1). history of laparoscopic cholecystectomy for one year. His abdominal X-ray showed a mass in the right upper Discussion & conclusion quadrant of abdomen (Fig. 11). CT scan showed that a PDH also known as mesocolic hernias are congenital part of small intestine and its mesentery were folded and derive from embryonary peritoneal anomalies and associated abnormal intestinal rotation . These Fig. 4 The defect in the transverse mesocolon was opened. M: Fig. 3 Transverse view of CT image showing the cluster of small mesocolon, IMV: inferior mesenteric vein, D: the ascending part intestine and its mesentery of duodenum, HS: hernia sac Shadhu et al. BMC Surgery (2018) 18:32 Page 4 of 7 Fig. 7 The defect in the transverse mesocolon. TC: transverse colon, D: the ascending part of duodenum, HO: hernia orifice Fig. 5 Transverse view of CT image showing the cluster of small intestine and its mesentery entrapped in the left side of abdomen, . The high rate of mortality associated with these beneath the left branch of middle mesenteric artery. The complications make early identification indispensable attenuated enhancement of the entrapped intestinal loop and justifies the role of abdominal CT in the early suggested intestinal ischemia pre-operative diagnosis of paraduodenal hernia. Multi- slice computer tomography (CT) offers high resolution patients usually present with chronic abdominal pain and multiplanar images which may be very demonstra- and vomiting with or without signs of intestinal obstruc- tive and characteristic providing a precise and early diag- tion . There is an associated risk of strangulation and nosis, useful for surgical treatment planning [6, 12]. In intestinal infarction for more than 50% over the course typical CT images, PDH shows a cluster of dilated bowel of a lifetime, making it necessary to investigate radio- segments with engorged and displaced mesenteric ves- logical signs of hypoperfusion and intestinal ischemia sels at the hernial orifice . Early surgical intervention is essential to avoid future complications because pa- tients with PDH have a 20–50% mortality for acute pre- sentations [15, 16]. A literature search was performed to identify the rare cases of paraduodenal hernia treated with laparoscopic approach. Only 28 case reports were published between January 1998, in which Uernatsu et al. . first described the minimally invasive treatment of this surgical emergency, and November 2015. The several advantages of laparoscopic approach, deduced Fig. 6 Coronary view of CT scan image showing the cluster of the Fig. 8 Transverse section of CT scan image showing the cluster small intestine of jejunum Shadhu et al. BMC Surgery (2018) 18:32 Page 5 of 7 Fig. 11 Abdominal X-ray showed a mass in the right upper quadrant of abdomen or interrupted suture, enlargement of defect or resection of the sac) and type of material used (adsorbable or not adsorbable, monofilament or poly-filament) [9, 10, 17–35]. We opted for laparoscopic approach for all our five Fig. 9 Coronary view of CT scan image showing the cluster of the patients who shared same benefits as described by small intestine other authors. Therefore, based on our experience and current after analysing data in previous cases, were: decrease in literatures, we believe that laparoscopic approach is the post-operative pain, reduced morbidity, early food optimum treatment strategy for patients with paraduo- resumption (1.33 average, 1–3), shorter hospital stay denal hernia, especially in health centres with strong (3.60 average, range 1–10). These benefits occurred re- experience of advanced laparoscopic surgery. Patients gardless of type of intervention (elective or emergency), with or without small bowel obstruction and type of repair (closure of hernial defect with continuous Fig. 10 The defect of transverse mesocolon was identified and Fig. 12 Transverse view of CT image showing the cluster of small closed with interrupted sutures. TC: transverse colon, D: the intestine and its mesentery on the right upper quadrant of abdomen ascending part of duodenum, HO: hernia orifice before the descending part of duodenum Shadhu et al. BMC Surgery (2018) 18:32 Page 6 of 7 Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent was obtained from the participants for publication of this article and any accompanying tables/images. A copy of the written consent is available for review by the Editor of this journal. Competing interests The authors declare that they have no competing interests. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details Department of General Surgery, Jiangsu Province Hospital, First Affiliated hospital of Nanjing Medical University, Guangzhou Road, 300, Gulou District, Nanjing 210029, Jiangsu Province, People’s Republic of China. Pancreas Center, Jiangsu Province Hospital, First Affiliated hospital of Nanjing Medical University, Guangzhou Road, 300, Gulou District, Nanjing 210029, Jiangsu Province, People’s Republic of China. Department of Breast Surgery, Jiangsu Province Hospital, First Affiliated hospital of Nanjing Medical University, Guangzhou Road, 300, Gulou District, Nanjing 210029, Jiangsu Province, People’s Republic of China. Department of Gastric Surgery, Jiangsu Province Hospital, First Affiliated hospital of Nanjing Medical University, Guangzhou Road, 300, Gulou District, Nanjing 210029, Jiangsu Province, People’s Republic of China. 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Published: May 30, 2018