Surgery of Left Paraduodenal Hernia Robert Davis, MB, BCh, FRCS (Edinb),” New York, New York Internal hernia is defined as the herniation of a viscus into a fossa, fovea, or foramen within the body cavity. A left paraduodenal hernia occurs in the paraduodenal fossa of Landzert. This space is to the left of and 2 cm from the ascending part of the duodenum and overlies the ligament of Treitz, which fixes the duodenojejunal flexure to the pos- terior abdominal wall. It is bound anteriorly by a fold of peritoneum that contains the inferior mes- enteric vein, accompanied by branches of the left colic artery. These vessels form the vascular arch of Treitz. A fossa forms beneath this arch, the mouth of which is open to the right and the apex of which points to the left toward the descending colon. It may be associated with two other fossae superiorly and inferiorly. (Figure 1.) The mouths of all these fossae point toward each other. The boundaries of the mouth of the left paraduodenal fossa are anteriorly the inferior mesenteric vein, superiorly and inferiorly the folds of the peritone- um, and posteriorly the posterior leaf of the peri- toneum. Paraduodenal fossae are seen most fre- quently in fetuses and newborn infants and are found in 2 per cent of subjects at autopsy [I]. Until 1964 fewer than 400 cases of paraduodenal hernia had been reported [2]. Paraduodenal hernia is the most common type (53 per cent) of internal hernia and 75 per cent occur on the left side [2,3]. Right and left paraduodenal hernias are distinct and separate entities, differing not only in ana- tomic structure but also in embryologic origin. Paraduodenal hernia was the cause in 0.9 per cent of cases of intestinal obstruction [4]. From the Department of Surgery, Albert Einstein Cdege of Medicine, Bronx, New York. * Present address and address for reprint requests: Department of Surgery, the University of Texas Medical Branch, Galveston, Texas 77550. Clinical Material Etiologic Factors. Moynihan [5] originally de- scribed nine different fossae located around the duodenum. He implied that induced intra-abdom- inal pressures force abdominal contents into a pre- formed fossa. Andrews [6], however, dismissed the idea that a normal anatomic paraduodenal fossa is etiologically responsible for the acquired develop- ment of an internal hernia. He emphasized that the hernia usually contained only small bowel and not omentum or other structures. He also noted that in 90 per cent of all cases the paraduodenal hernia contained a large amount (greater than half) of the small bowel. This observation has been confirmed frequently and was seen in the case re- ported herein. It is difficult to imagine a hernia this size resulting from acquired differential forces within one body cavity. Andrews’ suggestion (61 that an embryologic defect is responsible has formed the basis of current opinion [7-g]. Embryologic Features. In the fetus at the fifth week of development, the elongating midgut is forced out into the umbilical cord due to rapid growth of the abdominal viscera. The small bowel then rotates 270 degrees counterclockwise about the superior mesenteric axis, and at the end of the tenth week the midgut has returned very rapidly to the abdominal cavity. As the prearterial seg- ment returns behind and then to the left of the su- perior mesenteric artery, it eventually lies on the left side of the abdomen. The sequence of events is illustrated in Figure 2, which demonstrates the embryologic development of the hernia. The bowel may then invaginate into an unsupported area of descending mesocolon, the anterior margin of which is formed by the ascending branch of the in- ferior mesenteric artery and vein. As a result, the small bowel lies in a sac behind the peritoneum of 570 The American Journal of Suraerv
Transcript
Surgery of Left Paraduodenal Hernia
Robert Davis, MB, BCh, FRCS (Edinb),” New York, New York
Internal hernia is defined as the herniation of a viscus into a fossa, fovea, or foramen within the body cavity. A left paraduodenal hernia occurs in the paraduodenal fossa of Landzert. This space is to the left of and 2 cm from the ascending part of the duodenum and overlies the ligament of Treitz, which fixes the duodenojejunal flexure to the pos- terior abdominal wall. It is bound anteriorly by a fold of peritoneum that contains the inferior mes- enteric vein, accompanied by branches of the left colic artery. These vessels form the vascular arch of Treitz. A fossa forms beneath this arch, the mouth of which is open to the right and the apex of which points to the left toward the descending colon. It may be associated with two other fossae superiorly and inferiorly. (Figure 1.) The mouths of all these fossae point toward each other. The boundaries of the mouth of the left paraduodenal fossa are anteriorly the inferior mesenteric vein, superiorly and inferiorly the folds of the peritone- um, and posteriorly the posterior leaf of the peri-
toneum. Paraduodenal fossae are seen most fre- quently in fetuses and newborn infants and are found in 2 per cent of subjects at autopsy [I].
Until 1964 fewer than 400 cases of paraduodenal hernia had been reported [2]. Paraduodenal hernia is the most common type (53 per cent) of internal hernia and 75 per cent occur on the left side [2,3]. Right and left paraduodenal hernias are distinct and separate entities, differing not only in ana- tomic structure but also in embryologic origin. Paraduodenal hernia was the cause in 0.9 per cent of cases of intestinal obstruction [4].
From the Department of Surgery, Albert Einstein Cdege of Medicine, Bronx, New York.
* Present address and address for reprint requests: Department of Surgery, the University of Texas Medical Branch, Galveston, Texas 77550.
Clinical Material
Etiologic Factors. Moynihan [5] originally de- scribed nine different fossae located around the duodenum. He implied that induced intra-abdom- inal pressures force abdominal contents into a pre- formed fossa. Andrews [6], however, dismissed the idea that a normal anatomic paraduodenal fossa is etiologically responsible for the acquired develop- ment of an internal hernia. He emphasized that the hernia usually contained only small bowel and not omentum or other structures. He also noted that in 90 per cent of all cases the paraduodenal hernia contained a large amount (greater than half) of the small bowel. This observation has been confirmed frequently and was seen in the case re- ported herein. It is difficult to imagine a hernia this size resulting from acquired differential forces within one body cavity. Andrews’ suggestion (61 that an embryologic defect is responsible has formed the basis of current opinion [7-g].
Embryologic Features. In the fetus at the fifth week of development, the elongating midgut is forced out into the umbilical cord due to rapid growth of the abdominal viscera. The small bowel then rotates 270 degrees counterclockwise about the superior mesenteric axis, and at the end of the tenth week the midgut has returned very rapidly to the abdominal cavity. As the prearterial seg- ment returns behind and then to the left of the su- perior mesenteric artery, it eventually lies on the left side of the abdomen. The sequence of events is illustrated in Figure 2, which demonstrates the embryologic development of the hernia. The bowel may then invaginate into an unsupported area of descending mesocolon, the anterior margin of which is formed by the ascending branch of the in- ferior mesenteric artery and vein. As a result, the small bowel lies in a sac behind the peritoneum of
570 The American Journal of Suraerv
Paraduodenal Hernia
the descending colon [10,11]. (Figure SC.) Callan- der, Rusk, and Namir [II] described how the her- nia behind the inferior mesenteric vein and behind the mesocolon could occur. The herniated small bowel interferes with the posterior fixation of the descending colon so that a sac is formed that would normally be obliterated. The anterior sur- face of the sac is homologous with the anatomic posterior peritoneum of the adult. The length of the vessels in the anterior border of the mouth of the sac remains relatively constant so that the en- largement occurs to the left of the midline behind the fused anterior leaf of mesocolon.
In the normal process of development the inferi- or mesenteric vein becomes a retroperitoneal structure; the surgical approach, therefore, should be directed toward correcting the anomaly and placing the inferior mesenteric vein in a retroperi- toneal position.
Clinical Presentation. These hernias may pres- ent in four ways. They may be found incidentally at autopsy or laparotomy, or they may give rise to chronic digestive complaints or chronic or acute intestinal obstruction. Intestinal obstruction will be present in 50 per cent [12]. The radiologic fea- tures may assist in preoperative diagnosis. On the plain abdominal film coils of bowel will appear to be clumped together in one place with a semicircu- lar margin that does not change with position or manipulation. The axis of this mass is to the left of the midline. There might be an apparent absence of small bowel in the pelvis. Contrast study may
Jelunum reflected
xR1dg.z of patewar peritoneum rotsed the mf mesenter~c
bv Yei”
Figure 1. This represents the left paradwdenai spaces. The fossa of Landzert lies beneath the ridge of posterior peritoneum raised up by the inferior mesenteric vein.
reveal stasis in the herniated bowel, with loss of motility and delayed passage [1,13,14].
Treatment. Operative treatment of hernia en- countered at operation for another condition (for example, perforated duodenal ulcer) has been de- bated. The consensus favors operative reduction because of the risk of strangulation due to postop- erative distention and of later obstruction by ad- hesions [15,16]. The sequestration of infected ma- terial or of a leak in such a sac may be serious. Recognizing this anomaly at operation is also very important, as several serious errors may ensue [17,18].
The usual appearance of left paraduodenal her- nia at operation is depicted diagrammatically in Figure 3. The free border of the sac contains the
Figure 2. The development of the hdl paraduodenai hernia (tram?- verse sections of the i3bdominai cavtty looking cephaiad). A, dtspo- &ion of the intestines during return of the herntated small bowel into the abdominal cavity; B, the small bowel ioops are cfoseiy ad#cent to the proxbnai portion of the mesen- tery of the desc6nding coion; C, the hwps have hernfated behind the in- ferbr mesenterk vein and into the descending mesocoion. Theoe her- niated ioops intetfere with posterior fixation of the mesenterks so that the ttnal res& is the paraduodenai hernia as presented in D.
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Figure 3. Appearance of the left paradwdenal hernia at op&atlon, showing most of the small bowel Incarcerated in a sac entering beneath the inferlo mesenterk vein.
inferior mesenteric vein continuing upward to join the splenic vein retroperitoneally behind the pan- creas. The anterior wall of the sac also contains branches of the left colic artery, which extend over to the splenic flexure and descending colon.
Various operative maneuvers have been pro- posed. It is usually easy to reduce the coils of small intestine by a combination of traction and pres- sure. When this cannot be accomplished simply, other maneuvers, such as dilatation of the orifice by manual stretching, may be helpful [19]. Resis-
Inf mesenterlc
tance to reduction may be due to distended bowel and/or adhesions within the sac. Dissection of the adhesions after incision of the sac may then be necessary.
After reduction of the hernia, the defect is usu- ally closed utilizing sutures from the tissue around the inferior mesenteric vein to the tissue on the posterior abdominal wall. This does not complete- ly remove the projecting ridge caused by the infe- rior mesenteric vein and may indeed interfere with the patency of the vessel. Other authorities [IO,201 have suggested transection of the inferior mesen- teric vein, thus removing the constricting ring that forms the orifice of the internal hernia.
There have been no reports of recurrence of paraduodenal hernia after these operative proce- dures. However, the following technic is recom- mended on the basis of study of the embryologic and anatomic features of the anomaly.
Recommended Procedure. The objectives of op- erative repair should be to (1) reduce the hernia, (2) remove the sac, and (3) repair the defect. Ini- tially, the hernia should be reduced. (Figure 4B.) After this, the anterior wall of the sac should be excised from just left of the inferior mesenteric vein up to the descending colon, taking care not to injure the marginal artery of Drummond and thus avoiding the risk of compromising the blood sup- ply of the splenic flexure and descending colon. As a result of this maneuver the inferior mesenteric vein is isolated in an arch of tissue running be- tween the original upper and lower margins of the neck of the hernia. (Figures 4C and 5.)
Figure 4. Transverse sections through the abdomen looking ceph- alad. A, hernia of small bowel be- hind the lnferlor mesenterk vein; 8, reduction of the hernia; C, inckdoh in the posterior peritoneum after re- moval of the anterior wall of the sac; D, inferior mesenterk vein bur- led In its retroperitoneal bed.
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Edge of excision of
onter,or wall of the sac
deerxned throuah the
Figure 5. After excision of the anterior wall of the sac, an In&Ion Is made in the posterior peritoneum to the left of the duodeno/ejunal flexure.
An incision is then made in the posterior pari- eta1 peritoneum (the posterior wall of the sac) to the left of the duodenojejunal flexure, leaving a border of peritoneum at least 0.25 inches wide at- tached to the reflected bowel. The incision is con- tinued deeper through the ligament of Treitz, and the duodenojejunal flexure is reflected to the right. (Figure 5.) Sufficient blunt retroperitoneal dissec- tion is performed to create a retroperitoneal bed for the isolated inferior mesenteric vein. When the inferior mesenteric vein is placed in this bed, the previously reflected duodenojejunal flexure is re- placed in position over it and the previously cut edges of the posterior parietal peritoneum are reapproximated. (Figure 4D.) This procedure deals effectively with the mouth of the sac and the embryologic defect.
Case Report
A thirty-one year old Puerto Rican man presented with a history of acute upper abdominal pain followed by vomiting for two hours before admission. He had had heartburn and indigestion intermittently over the past three years. He was awakened nightly by the pain, which also occurred before meals and was relieved by antacids. He gave a longer history (approximately five years) of intermittent episodes of periumbilical colicky abdomi- nal pain that resolved spontaneously after about thirty minutes.
On examination he had upper abdominal rigidity and no bowel sounds. Erect x-ray film of the abdomen dem- onstrated free air under both diaphragms. A perforated duodenal ulcer was diagnosed. At operation, perforation of a chronic ulcer of the anterior wall was found in the first part of the duodenum. There was minimal perito- neal contamination and no evidence of peritonitis at this time. Weinberg pyloroplasty utilizing interrupted silk sutures was performed, followed by truncal vagotomy.
Further exploration of the abdomen revealed 75 per cent of the small bowel (from the duodenojejunal flexure
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to two feet from the cecum) incarcerated in a left para- duodenal hernia. The findings were identical with those described previously and the recommended operative procedure was performed. The patient had an unevent- ful postoperative course and remains asymptomatic.
Summary
The clinical presentation, embryologic and etio- logic factors, and repair of left paraduodenal her- nia are presented. A new operative procedure for cure of left paraduodenal hernia is presented that deals effectively with the sac and predisposing arch containing the inferior mesenteric vein with- out section of the vein. Repair is based upon the embryologically normal anatomy with restoration of the inferior mesenteric vein to its normal retro- peritoneal position. This procedure has been suc- cessfully utilized in a case in which the paraduode- nal hernia of small bowel was encountered con- comitantly with a perforated duodenal ulcer.
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