Right Paraduodenal Hernia With Intestinal Malrotation Presenting Diagnostic Difficulties: A Case Report

Abstract

A 13-year-old boy presented to the emergency department of our hospital with intermittent abdominal pain and a large amount of bloody emesis and melena. While he had no history of abdominal surgery, he had been admitted twice to our hospital for similar symptoms in the past year. He underwent computed tomography, Meckel scintigraphy, esophagogastroduodenoscopy and total colonoscopy examinations, but the cause of his symptoms was unknown. However, an upper gastrointestinal examination (UGI) showed that the duodenum and proximal small bowel were shifted entirely to the right of the right pedicles (with no Treitz ligament). A subsequent small bowel follow-through (SBFT) examination showed a cluster of loops with a smooth margin on the right. We conducted laparoscopic surgery for malrotation. The operative findings showed a right retrocolic mass defect from a herniated jejunum with the paraduodenal hernia (PDH) sac. The hernia orifice and jejunum efferent from the PDH sac to the left and second portions of the duodenum entered into the PDH sac. We then performed surgery to open the PDH sac with Ladd’s operation for right PDH with intestinal malrotation. The course of this disease varies, including both long-duration (or chronic) symptoms and sudden symptoms with abdominal pain, vomiting and strangulated obstruction requiring resection of the small intestine. We considered the obstruction as the cause of the gastrointestinal bleeding. It is critical to make an accurate diagnosis and provide the appropriate surgical treatment for this disease.