Left paraduodenal hernia: an unusual cause of small-bowel obstruction.

A 35-year-old man presented with a 10-day history of recurrent crampy abdominal pain, distension, nausea, vomiting and alternating constipation and diarrhea. His medical history was significant for an appendectomy, done many years earlier. Physical examination revealed dehydration and some abdominal distension but no visible external hernia. Smallbowel follow-through with barium and intraoperative images (Fig. 1) showed barium exiting slowly from the stomach (Fig. 1A) then filling a sac-like “cocoon” structure (Fig. 1B). The barium did not exit from the encysted bowel until 3 hours later (Fig. 1C), and finally reached the colon after 4 hours (Fig. 1D). At laparotomy, the distended small bowel was visible through the gastrocolic omentum (Fig. 1E). During reduction the collapsed distal and distended proximal small bowel was seen to pass through a defect in the transverse mesocolon (Fig. 1F). The small bowel was reduced back into the infracolic compartment where it was found to be viable, and the hernial sac was excised. The peritoneal defect was closed with interrupted nonabsorbable sutures. The jejunum at the ligament of Treitz was affixed to the posterior parietal peritoneum to prevent it from sliding superiorly. The patient’s postoperative recovery was uncomplicated, but months later a smallbowel obstruction necessitated a second laparotomy for lysis of multiple adhesions. At that time, the hernial defect was well sealed.