peritoneal encapsulation, left paraduodenal hernia with … · 2018. 12. 10. · axial and coronal...

IJCRI – International Journal of Case Reports and Images, Vol. 4 No. 3, March 201 3. ISSN – [0976-31 98]

IJCRI 201 3;4(3):1 69–1 74.www.ijcasereportsandimages.com

Peritoneal encapsulation, left paraduodenal hernia withretroperitonealization of inferior mesenteric vein leadingto triple obstructionImtiaz Wani, Khursheed A Wani, Muneer Wani, Gulzar Bhat,Mubashir Shah

ABSTRACTIntroduction: Encasing of small bowel in ananomalous accessory membrane results inperitoneal encapsulation and is a very rarecause of intestinal obstruction. It is believed tobe caused by malrotation of the bowel duringthe 12th week of gestation and this causes theformation of an accessory sac from theperitoneum, covering the umbilicus. Leftparaduodenal hernia is the most common formof congenital internal hernia. Paraduodenalhernia are caused by abnormal rotation of themidgut during embryonic development. Thisrarely presents as an intestinal obstruction.Congenital adhesions are rare in adults andthese may lead to retroperitonealization ofinferior mesenteric vein (IMV). Case Report: Acase of peritoneal encapsulation and leftparaduodenal hernia with congenital adhesionsleading to retroperitonealization of inferiormesenteric vein (IMV) in the same patient isreported here. A 28yearold male presentedwith recurrent small bowel obstruction and wasdiagnosed with an intestinal obstruction.Computed tomography confirmed peritonealencapsulation and left paraduodenal herniawith features of intestinal obstruction. Excisionof membrane and reduction of hernia withretroperitonealization of inferior mesenteric

vein was done. Conclusion: This is the first casereported in literature where peritonealencapsulation, paraduodenal hernia andretroperitonealization of inferior mesentericvein (IMV) occurred together and lead to bowelobstruction. In this case, the origin of threeabnormal anatomical structures must have beencongenital as there was no history of priorsurgery.Keywords: Encapsulation, Paraduodenal,inferior mesenteric vein (IMV)

*********Wani I, Wani KA, Wani M, Bhat G, Shah M. Peritonealencapsulation, left paraduodenal hernia withretroperitonealization of inferior mesenteric veinleading to triple obstruction. International Journal ofCase Reports and Images 2013;4(3):169–174.

*********doi:10.5348/ijcri201303287CR8

INTRODUCTIONThe peritoneal encapsulation, first described byCleland [1] in 1868, is a rare developmental abnormalityin which part or the entire small bowel is encased in anaccessory sac. It is believed to be caused by malrotationof the bowel during the 12th week of gestation and thiscauses the formation of an accessory sac from theperitoneum covering the umbilicus [2]. The incidence ofthis condition is not well known. There are not morethan 50 to 60 cases described in literature [3–5]. Mostof the cases remain asymptomatic; diagnosed usually asan incidental finding during surgery for unrelatedconditions and only rarely present as bowel obstruction[6–8]. Paraduodenal hernia is the most common type ofintestinal hernia, accounting for 30–53% of all cases

CASE REPORT OPEN ACCESS

Imtiaz Wani1 , Khursheed A Wani1 , Muneer Wani1 , GulzarBhat1 , Mubashir Shah1

Affi l iations: 1Department of General Surgery, SKIMS,Srinagar, Kashmir, India.Corresponding Author: Imtiaz Wani, Department ofGeneral Surgery, SKIMS, Srinagar, Kashmir, India -1 90009; Ph: 941 90051 69

Received: 1 7 August 201 2Accepted: 1 5 October 201 2Published: 01 March 201 3

Wani et al. 1 69


IJCRI 201 3;4(3):1 69–1 74.www.ijcasereportsandimages.com Wani et al. 1 70

and accounts for 0.2–0.9% of all bowel obstructions [9].This hernia has a variable clinical manifestation andrarely may present as an acute abdomen. In adults,occurrence of congenital bands is an extremely rarecondition [10, 11]. The entrapment of the intestinebetween the bands and the mesentery or bycompression of the bowel leads to obstruction. Rarely avessel with an abnormal position compressing on thegut could lead to bowel obstruction [3].Clinical diagnosis of bowel obstruction is oftendifficult to make due to ambiguous presentation inperitoneal encapsulation, paraduodenal hernia, congenitalbands and an abnormal vessel compressing the gut[12–14]. Xray of abdomen, ultrasonography, bariumstudy and computed tomography are contributory indiagnosis of each form of obstruction. The excision ofmembrane in peritoneal encapsulation is recommendedeven if this condition is diagnosed incidentally. Allparaduodenal hernias must be repaired, including thosethat are asymptomatic [15]. Release of adhesions incongenital bands and the retroperitonealization ofvessel leading to obstruction is recommended.

CASE REPORTA 28yearold male presented with generalizedabdominal pain, fever and multiple episodes ofvomiting. Abdominal pain was episodic and colicky andvomitus was bilious. There was no past history oftrauma or surgery. Patient had a past history of threeepisodes of similar abdominal pain and vomiting threemonths back. Second episode occurred 12 days after thefirst episode and third episode occurred 21 days afterfirst episode. Patient was diagnosed as a case ofrecurrent subacute intestinal obstruction by small gutstricture which was confirmed on the barium study atthat time. During and after each episode the patient wasmanaged conservatively without any surgicalintervention. General physical examination duringcurrent episode showed dehydrated appearence, pulse96/min, blood pressure 110/70 mmHg, andtemperature of 99oC. Systemic examination was normal.Abdominal examination revealed distended abdomen,diffuse tenderness and a high pitch bowel sounds.Laboratory parameters were normal. Xray ofabdomen showed multiple air fluid levels. Computedtomography scan of the abdomen revealedconglomeration of gut in a thin sac suggestive ofperitoneal encapsulation on the right side. There wasdisplacement of inferior mesenteric vein and theentrapped bowel in left upper abdomen (leftparaduodenal hernia) (Figure 1A–B).Gut loops weredilated and had thick walls. Exploratory laparotomyrevealed encasement of bowel loops in membrane,typical of peritoneal encapsulation with interloopadhesions present in the bowel outside the peritonealsac (Figure 2). Gut inside peritoneal encapsulation wasdilated, which was suggestive of obstruction.Malrotations of small gut loops was seen. After carefuldissection of the membrane, adhesiolysis and release of

omental adhesions, a vessel lying on ileal loops, outsidethe retroperitoneum, was seen which was identified asinferior mesenteric vein (IMV) (Figure 3A–B). The bowelproximal to the abnormally placed IMV was dilatedwith thickened wall which was suggestive of obstruction.This abnormally lying IMV was constrained byadhesions to small bowel. Peritoneal encapsulation andretroperitonealization of IMV were leading to subacuteintestinal obstruction. Further exploration revealed aloop of intestine impacted in a left paraduodenal fossa.Diagnosis of the left paraduodenal hernia wasconfirmed (Figure 4A–B). Incarcerated segment ofbowel in left paraduodenal fossa had signs ofstrangulation with thickened walls leading to acuteabdomen. Resection of incarcerated segment and theclosure of hernial orifice was done. Retroperitonealizationof anteriorly placed IMV was achieved. Postoperativeperiod was uneventful and patient was discharged afterone week. Patient is well on follow up for last 13 months.

Figure 1(A, B): Computed tomography scan of the abdomen inaxial and coronal cuts demonstrating left paraduodenal hernia.Arrows are outlining the hernial sac, with clustered, sharplycircumscribed loops of small bowel in the left upper abdomen.In right lower abdomen gut loops conglomerated in peritonealsac.

Figure 2: Bowel encased in a membrane suggestive ofperitoneal encapsulation.



DISCUSSIONPeritoneal encapsulation is a developmentalabnormality encasing part or the entire small bowel inan accessory sac derived from the yolk sac [16]. Theaccessory peritoneal membrane is derived from theperitoneum of the yolk sac which withdraws into theabdominal cavity with the small bowel instead ofremaining at the base of the umbilical cord. This isattached to the ascending and descending colonlaterally, the transverse mesocolon superiorly andmerges with posterior parietal peritoneum inferiorly.The membrane has two openings, one around theduodenojejunal flexure and the other at the ileocecaljunction [7]. Peritoneal encapsulation seems to bepredominant in males and is not always associated withabnormal intestinal rotation [17, 18] . The condition islargely asymptomatic but some cases may present asbowel obstruction [19, 20]. Peritoneal encapsulationvery rarely leads to an acute iliac occlusion or toidiopathic sclerosing peritonitis [21, 22]. This congenitalencapsulation can be diagnosed incidentally duringlaparotomy for other conditions and some cases arediagnosed at autopsy [3, 8]. It can occur withincomplete situs inversus and abnormal artery (both arecongenital anomalies) or as an incidental findings attime of gastric surgery or during colon cancer surgery[4, 23].Paraduodenal hernia is a rare condition in which thesmall bowel loops are trapped within a congenitalparaduodenal fossa [24]. Males are three times moreaffected than females [25]. Paraduodenal hernia aredivided into two subtypes: left or right paraduodenalhernia. About 75% are located on the left side [9]. A caseof congenital pyloric stenosis associated with thepresence of a paraduodenal hernia in an adult patienthas been reported [26]. Paraduodenal hernia lacks atrue hernial sac and is termed ‘prolapse’ or ‘procidentia’rather than a hernia [27 ]. The left paraduodenal herniais a result of anomalous rotation of midgut into thedeveloping mesentery of the descending colon withmechanical forces of fluctuating intraabdominalpressure leading to herniation in places where theperitoneum is yet incompletely fused [27, 28]. Theyoriginate at the fossa of Landzert which is just lateral tothe fourth segment of the duodenum and behind theinferior mesenteric vein and ascending left colic artery[29]. The sac lies to left of the duodenum. Inferiormesenteric vessels constitute the anterior free margin ofthe sac [30]. Accurate anatomy is important surgically,as the inferior border of the hernia opening is safestplace to widen the neck of the hernia [27].Symptoms of paraduodenal hernia are nonspecific,ranging from recurrent vague abdominal pain, nausea,vomiting and reversible obstruction leading to an acuteabdomen [31]. About 50% cases follow an asymptomaticclinical course and are diagnosed incidentally; rest 50%patients with paraduodenal hernia have episodes ofintestinal obstruction at some point of their lives [32].The symptoms depend on patient's position, withsymptoms aggravating while standing and relieved in a

Figure 3(A, B): Gut loops compressed by inferior mesentericvein lying in the retroperitoneum and site ofretroperitonealisation of inferior mesenteric vein.

Figure 4(A, B): Left paraduodenal hernia impacted inparaduodenal fossa and the incarcerated gut (arrow).



supine position [33]. Spontaneous reduction apparentlycauses the periodic presentation of abdominal pain withnormal radiographic studies [34]. The herniated smallbowel loops may become trapped within this mesentericsac. Symptoms may also result from retroperitonealmass effect.Adhesions are the cause of about 30–41% of allintestinal obstructions and for the small bowelobstruction, the proportion rises to 65–75% [35]. Only3% of these are thought to be caused by congenitalomental bands formed by abnormal adhesions of theperitoneal folds during embryogenesis [10, 36]. In ourcase, congenital adhesions might have led toconstraining effect on IMV leading to itsretroperitonealization which compressed the smallbowel leading to obstruction. A congenital constrainingof adhesions between the vein and the gut can also leadto bowel obstruction.In view of the diagnostic difficulty based on clinicalfindings, imaging studies often play an important rolein the diagnosis. Radiographic studies are usuallynormal or show nonspecific features of intestinalobstruction. Plain abdominal Xrays are suggestive ofmechanical bowel obstruction which was present in ourcase. A paraduodenal hernia may be demonstrated byan upper gastrointestinal series performed during aperiod of acute symptoms. Barium contrast studydemonstrates saclike mass of mildly dilated jejunalloops, left of the ligament of Treitz with mass effectcausing displacement of the greater curvature andposterior wall of the stomach [37 ]. Ultrasonography ininternal hernia shows hetergenous echoic abdominalmass with presence of changing cystic or tubularinternal components and a surrounding the membrane[38]. On computed tomography (CT) scan, the findingsare very nonspecific. Small bowel is seen enveloped ina thin membrane and may be suggestive of peritonealencapsulation [20, 23, 39]. The following findings areseen on CT scan in left paraduodenal hernia [27, 40, 41]:(a) A focal cluster of small bowel loops positionedabnormally between the pancreatic body or tailand the stomach lying to the left side ofligament of Treitz or behind the descendingcolon and distal transverse colon.(b) Bowel loops proximal and within hernial sacshow dilatation with air fluid levels.(c) Narrowing of efferent loops of bowel.(d) Mass effect causing displacement andindentation of posterior wall of stomach,inferior displacement of duodenojejunaljunction and transverse colon and medialdisplacement of the descending colon.(e) Inferior mesenteric vein and ascending leftcolic artery being displaced anterolaterally orupward.(f) Normal vascular relationship, although theremight be mild displacement caused by theherniated loops.(g) Mesenteric vessels that supply the herniatedsmall bowel segments show crowding at theentrance of hernial sac and the vessels inhernial sac are engorged.

(h) Normal vascular relationship of superiormesenteric artery and vein are usuallymaintained.Congenital adhesions involve surgical release ofadhesions and bands. Treatment of peritonealencapsulation involves the total removal of theanomalous membrane and release of both openings.Bowel resection may be necessary if the membranecannot be stripped atraumatically or if obviousgangrene of the bowel is present. There is no reoperation reported in literature after dividing theencasing membrane in peritoneal encapsulation [4].Surgical treatment of left paraduodenal herniafollows the basic principles of hernia surgery: reductionof the contents, restoration of normal anatomy andrepair of the defect [33, 42]. A retroperitonealization ofinferior mesenteric vein involves retroperitonealizationof vein after release of congenital adhesions.

CONCLUSIONOccurrence of paraduodenal hernia, peritonealencapsulation and congenital adhesions leadingretroperitonealization of inferior mesenteric vein in thesame patient is rare. Left paraduodenal hernia rarelypresents as an acute abdomen. Occurring of threeabnormal anatomical structures must have had acongenital origin as the patient had no predisposingfactors for the development of these congenitalanamolies.

*********Author ContributionsImtiaz Wani – Substantial contributions to conceptionand design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedKhursheed A Wani – Substantial contributions toconception and design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedMuneer Wani – Substantial contributions to conceptionand design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedGulzar Bhat – Substantial contributions to conceptionand design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be publishedMubashir Shah – Substantial contributions toconception and design, Acquisition of data, Analysis andinterpretation of data, Drafting the article, Revising itcritically for important intellectual content, Finalapproval of the version to be published



GuarantorThe corresponding author is the guarantor ofsubmission.Conflict of InterestAuthors declare no conflict of interest.Copyright© Imtiaz Wani et al. 2013; This article is distributedunder the terms of Creative Commons Attribution 3.0License which permits unrestricted use, distributionand reproduction in any means provided the originalauthors and original publisher are properly credited.(Please see www.ijcasereportsandimages.com/copyrightpolicy.php for more information.)

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