左側十二指腸旁腹內疝氣合併腸阻塞 Left Paraduodenal Hernia with Small Bowel Obstruction 謝閔傑 江慶鐘 涂啟文 廖志思 嘉義基督教醫院 外科部 一般外科 Left Paraduodenal Hernia with Small Bowel Obstruction Min-Chieh Shieh, Ching-Chung Chiang, Chi-Wen Tu, Chi-Szu Liao Division of General Surgery, Department of Surgery, Chia-Yi Christian Hospital Discussion: The cause of left paraduodenal hernia is thought to result from failure of normal counter-clockwise rotation of the mid-gut around the superior mesenteric artery during embryological development. Although congenital, most left paraduodenal hernias are diagnosed during the 4-6th decade of life with the average age of diagnosis being 38.5 years. 3. They are often difficult to diagnose, as the most common presentation is rather non-specific. The presentation ranges in severity from recurrent vague abdominal pain, tenderness, nausea in partial incomplete obstruction, to acute abdomen in cases of incarceration. 4. Contrast enhanced computed tomography is the best imaging modality in the diagnosis of left paraduodenal hernia. CT may show focal cluster of small bowel abnormally positioned between the stomach and the pancreas 5. Once the accurate diagnosis is made, the treatment is surgical intervention. The incarcerated viscera are reduced manually. In case of difficult reduction, such as bulky bowel incarceration or severe adhesion, inferior based incision in the avascular portion of the hernia sac is made to restore the normal anatomy of viscera. 6. Laparoscopic approach is reported to be the promising alternative management in repair of left paraduodenal hernia and it carries all of the benefit of minimally invasive surgery and cause less suffering in the patients. Summary: Although rare, left paraduodenal hernias should be included in the differential diagnosis of small bowel obstruction patients who lack any history of previous abdominal surgery. The combination of a high clinical suspicion, more understanding this disease entity and modern imaging technology make preoperative diagnosis easier today. Once diagnosed, left paraduodenal hernias should be surgically repaired because they carry 50% lifetime risk of incarceration, leading to bowel obstruction and strangulation. Timely surgical intervention effectively relieves the patient’s suffering and prevents further complications. Introduction: Left paraduodenal hernias are the most common type of congenital internal hernias, with over 400 cases having been reported in the literature. Clinical presentation can range from acute intestinal obstruction to an extended history of non-specific vague abdominal pain, often relived by changes in positions. The present report describes a case of left paraduodenal hernia presenting as acute small bowel obstruction. Case Report: A 51 year-old man had suffered from progressive abdominal distension and bilious vomiting for one day. He did not have past history of abdominal surgery. The abdominal examination revealed significant distension at left upper quadrant of abdomen and periumbilical local tenderness. The plain abdominal X-ray revealed dilatation of the small bowel loop. The contrast-enhanced abdominal CT showed localized small bowel loops in left upper abdomen with dilatation of the 3rd portion duodenum and collapse of distal bowel. Emergent laparotomy confirmed the diagnosis of left paraduodenal hernia around the Treitz ligament with small bowel incarceration and obstruction. The patient underwent the reduction of the incarcerated small bowel loops and simple closure of the peritoneal sac. The postoperative course was uneventful and the patient was discharged on the 7th post-operative day. Fig. 1 CT confirmed the presence of localized small bowel loops in left upper abdomen Fig. 2 Sagittal view of CT revealed small bowel loops aggregation at left upper abdomen with distension of 3rd portion duodenum and collapse of distalbowel