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CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 222-224

Left-sided mesocolic hernia presenting as internal Maydl's hernia, complicated by jejunal volvulus


Depatments of General Surgery and Paediatric Surgery, Dr. PSIMS and Research Foundation, Chinoutpalli, Gannavaram, Krishna District, Andhra Pradesh, India

Date of Submission10-Jan-2019
Date of Acceptance06-Sep-2019
Date of Web Publication17-Oct-2019

Correspondence Address:
Dr. Rajababu Pakanati
303, Vemula Residency, Chalasani Venkata Krishniah Street, Suryaraopet, Vijayawada - 520 002, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_5_19

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  Abstract 


Left mesocolic hernia (syn – left paraduodenal hernia/hernia of Landzert) is a type of internal hernia which occurs due to malrotation of the midgut and forms a potential space near the ligament of trietz. Prompt diagnosis is crucial to prevent strangulation. We report a rare case of left mesocolic hernia presenting as internal Maydl's hernia complicated by jejunal volulus, presenting as acute abdomen. An emergency derotation and reduction of small bowel was done with repair of the defect.

Keywords: Internal hernia, jejunal volvulus, Maydl's hernia, mesocolic hernia, paraduodenal hernia


How to cite this article:
Pakanati R, Prasad G V, Reddy B R, Swathi B. Left-sided mesocolic hernia presenting as internal Maydl's hernia, complicated by jejunal volvulus. J NTR Univ Health Sci 2019;8:222-4

How to cite this URL:
Pakanati R, Prasad G V, Reddy B R, Swathi B. Left-sided mesocolic hernia presenting as internal Maydl's hernia, complicated by jejunal volvulus. J NTR Univ Health Sci [serial online] 2019 [cited 2019 Nov 15];8:222-4. Available from: http://www.jdrntruhs.org/text.asp?2019/8/3/222/269485




  Introduction Top


An internal hernia is protrusion of the viscera through an opening in the mesentry or peritoneum. Internal hernia of the small bowel is a relatively rare cause of intestinal obstruction and accounts for less than 2% of all causes.[1] Mesocolic hernia (paraduodenal hernia) is a type of internal hernia. We report a rare case of left mesocolic hernia presenting as internal Maydl's hernia complicated by jejunal volvulus, without strangulation.


  Case Report Top


A 55-year-old female presented with diffuse pain in the abdomen of 1 week duration which had increased in intensity since 1 day. Pain was associated with vomiting which was nonbilious and the patient had no bowel movement since 2 days. She had a history of bilateral tubectomy 30 years back and abdominal hysterectomy 18 years back. She is a known case of type 2 diabetes mellitus, on regular medication with well-controlled blood sugars. On examination, her temperature was normal, pulse rate was 90/min, and blood pressure was 110/90 mmHg. Heart and lungs were clinically normal. Perabdominal findings revealed distention of the abdomen with tender ill-defined mass in the left lumbar and umbilical regions. The patient's routine investigations were normal. Plain erect abdomen X-ray revealed distended small bowel loops. Computed tomography (CT) scan of the abdomen revealed loops of dilated small intestine at jejunoileal junction possibly volvulus in the anticlockwise direction at the jejunoileal region.

Intraoperative findings

A globular hernial sac of approximately 25 × 25 cm was noted containing jejunum [Figure 1] and [Figure 2]. The inferior mesenteric vein was traversing vertically across the oval-shaped neck of the sac, placed anteriorly in relation with the neck of the sac [Figure 3] and [Figure 4]. Jejunal volvulus was seen in the anticlockwise direction protruding from the neck of the sac. The afferent loop being the proximal jejunum and the efferent loop being the distal jejunum posterior to the inferior mesenteric vein. A mid jejunal loop arising from the sac was protruding through the small defect behind the inferior mesenteric vein presenting as internal Maydl's hernia complicated by volvulus.
Figure 1: Schematic diagram, showing the extent of the sac

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Figure 2: Showing the defect and jejunal loop

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Figure 3: Schematic diagram, showing the sac,the inferior mesenteric vein and the line of division of the sac

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Figure 4: Showing, (A) The reduction of entrapped jejunal loop from underneath the inferior mesenteric vein and (B) The line of division of the sac

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Surgical procedure

A vertical incision was given on the anterior wall of the sac approximately 5 cm from the anterior edge of the neck of the sac, thereby facilitating to undo the volvulus of the jejunum, as also to pull the contents (jejunum) of the sac underneath the inferior mesenteric vein, hence restoring normal anatomy, from the duodenojejunal flexure to jejunoileal junction. The cut medial aspect of the sac was wrapped anterior to the inferior mesenteric vein and sutured to the left leaf of the proximal jejunal mesentry, thus obliterating the defect. The redundant sac (left lateral part) was closed with capitonnage. A tube drain was placed in the left paracolic gutter and the abdomen was closed in layers [Figure 4].


  Discussion Top


Mesocolic hernias are one of the cause of internal hernias, with left paraduodenal hernia (hernia of landzert) three times more common than right paraduodenal hernia (Waldeyer's hernia).[2] These hernias occur due to malrotation of the midgut. Alternatively, a genetic etiology has been suggested given the association between transmesenteric hernia and other anamolies including cystic fibrosis and hirschprung disease.[3]

Anatomical consideration of left mesocolic hernia

The left mesocolic hernia represents a herniation of the small intestine into fossa near the fourth part of the duodenum. The paraduodenal fossa (of Landzert) is most often incremented. The superior portion of this fossa is rimmed by inferior mesenteric vein.

Clinical features

The symptoms are quiet variable varying from mild abdominal cramps or occasional vomiting to acute intestinal obstruction. Postprandial pain with postural variation is a characteristic symptom. Inferior mesenteric vein compression in left paraduodenal hernias may lead to hemorrhoids.[4] Internal hernia may be complicated by gangrenous bowel, perforation, or volvulus.[5]

Investigation

CT is the imaging modality of choice in diagnosing a mesocolic hernia. A CT scan here demonstrates clustering of loops of small bowel at or above the ligament of treitz.[6],[7],[8]

Treatment

Timely surgical intervention is necessary, due to very high probability of incarceration or strangulation during life time. An exploratory lapratomy with reduction of hernia and closure of the defect is advised in case of obstruction.

There is controversy regarding whether an asymptomatic paraduodenal hernia incidentally found at operation for another cause should be reduced.[9] Serious surgical errors have been made at laparotomy, for example, gastroileostomy, when the presence of a paraduodenal hernia was not appreciated.[10]


  Conclusion Top


We report a rare case of left mesocolic hernia presenting as internal Maydl's hernia complicated by jejunal volvulus, without strangulation.

An early diagnosis and exploratory laparotomy has prevented morbidity and mortality in this patient. The insidious onset of this surgical emergency reaffirms the importance of surgeons maintaining a high index of suspicion for a transmesenteric hernia in patients with nonspecific clinical and radiological signs.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Blachar A, Federle MP, Dodson SF. Internal hernia: Clinical and imaging findings in 17 patients with emphasis on CT criteria. Radiology 2001; 218:68-74.  Back to cited text no. 1
    
2.
Khan MA, Lo AY, Vande Maele DM. Paraduodenal hernia. Am Surg 1998,64:1218-22.  Back to cited text no. 2
    
3.
Olazabal A, Guasch I, Casas D. Case report: CT diagnosis of nonobstructive left paraduodenal hernia. Clin Radiol 1992;46:288-9.  Back to cited text no. 3
    
4.
Mayers MA. Internal abdominal hernias. In: Mayers MA, editor. Dynamic Radiology of the Abdomen. 5th ed. New York, NY: Springer-Verlag, 2000. p. 711-48.  Back to cited text no. 4
    
5.
Newson BD, Kukora JS. Congenital and acquired internal hernias: Unusual causes of small bowel obstruction. Am J Surg 1986;152: 279-85.  Back to cited text no. 5
    
6.
Falk GA, Yurcisin BJ, Sell HS. Left paraduodenal hernia: Case report and review of the literature. BMJ Case Rep 2010;2010:pii: bcr0420102936.  Back to cited text no. 6
    
7.
Osadchy A, Weisenberg N, Wiener Y, Shapiro-Feinberg M, Zissin R. Small bowel obstruction related to left-side paraduodenal hernia: CT findings. Abdom Imaging 2005;30:53-5.  Back to cited text no. 7
    
8.
Warshauer DM, Mauro MA. CT diagnosis of paraduodenal hernia. Gastrointest Radiol 1992;17:13-5.  Back to cited text no. 8
    
9.
Berardi RS. Paraduodenal hernias. Surg Gynecol Obstet 1981; 152:99-l10.  Back to cited text no. 9
    
10.
Bartlett MK, Wang C, Williams WH. The surgical management of paraduodenal hernia. Ann Surg 1968;168:249-54.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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