Henry Ford Health Sterling Heights, Michigan, United States
Introduction/Purpose: Herniation of visceral organs through anatomy or surgically created defects is common, however the presentation for each type of hernia can vary. Duodenal defects are thought to be a result of anatomical malrotation during embryonic development, leading to incomplete closures of retroduodenal spaces. (7) Left and right paraduodenal defects differ due to their position in relation to the duodenum. A left paraduodenal hernia results from a patent Fossa of Landzert, allowing structures to herniate more inferiorly of the duodenum to the left. Less commonly a right paraduodenal hernia occurs due to the Fossa of Waldeyer, as visceral structures herniate to the right of the duodenum.
These hernias are commonly known to cause small bowel obstructions as some or all of the bowel herniates through the defect. There are limited reports on these defects causing large bowel obstructions, or cecal volvulus. Furthermore the preferred management of a cecal volvulus secondary to a paraduodenal hernia is far more limited.
Methods or Case Description: A healthy 50 y.o. male with a past medical history significant for hypertension, presented to the emergency room with nausea, vomiting, and abdominal pain for one day. Patient reported that he had been unable to pass flatus throughout the day with increased belching. He denied a history of past abdominal surgery, or any similar symptoms in the past. On physical exam his abdomen was obviously distended, mildly tender to palpation, without signs of peritonitis. Work up significant for a leukocytosis of 18,000, otherwise the patient was hemodynamically stable. CT abdomen pelvis with IV contrast revealed a cecal volvulus with a distended portion of colon in the left upper quadrant.
In the operating room an exploratory laparotomy was performed. Dilated cecum was observed in the left upper quadrant and some small bowel was visualized in the right lower quadrant. The cecum was detorsed and small bowel adhesions to the colonic mesentery were observed and taken down. While attempting to run the small bowel a hernia was noted in the sub duodenal space which appeared to contain the ileum and most of the jejunum. The small bowel was reduced and the Fossa of Waldeyer was closed. Once the remaining small bowel, large bowel, and mesenteric adhesions were divided the small bowel was run in its entirety and a right hemicolectomy was performed.
Outcomes: Immediately post-op the patient was stable and transferred to the GPU. However post-op day 2 the patient was noted to have melanotic stools, tachycardia requiring blood transfusion, and a transfer to the ICU. The bleeding was likely from the staple line, and resolved without further intervention. His hospital stay was further elongated due to an ileus. By post operative day 8 the patient was tolerating a regular diet and having regular bowel movements. He continues to do well when seen outpatient.
Conclusion: More accurate identification of anatomical abnormalities through imaging and broadening possible causes of common diagnoses allows further informed decision making during the operative procedure. Although paraduodenal hernias are historically more likely to present as small bowel obstructions the same pathology can lead to cecal volvulus. The pathological adhesions secondary to the original congenital malrotation of the bowel that lead to the paraduodenal hernia, and lack of retroperitoneal fixation of the large bowel allowed the abnormal movement that lead to a cecal volvulus.
Although this patient had to be transferred to the ICU a right hemicolectomy was necessary to mitigate future morbidity. In adults a retrospective analysis of surgical options found high mortality after detorsion and cecopexy compared to ileo-cecetomy (11). In this case closure of the defect and right hemicolectomy was warranted; but would the same interventions be performed if these abnormalities lead to chronic obstructive symptoms? Although such preemptive treatment has been studied in the pediatric population (10), formal screening and management does not yet exist for adults.
Cecal volvulus in the presence of malrotation and small bowel paraduodenal herniation is rare, but is a diagnosis that can present acutely in adults without prior symptoms.
