Aim: The aim of the study was to highlight the diagnostic dilemma in diagnosis of right paraduodenal hernia.
Background: Internal abdominal hernias account for nearly 0.9% of all intestinal obstructions. Paraduodenal hernias (PDH) constitute nearly 50% of all internal hernias, left PDH being 3 times more common than right PDH. Initial presentation is nonspecific, but if missed can present with catastrophic outcomes (i.e., small bowel obstruction, ischemia, and bowel perforation).
Case description: A 38-years-old gentlemen was presented to emergency department with acute onset, intermittent colicky pain abdomen in the right lower quadrant with 2 episodes of vomiting of one-day duration. On examination, fullness in the right lumbar and iliac fossa region was noted and bowel sounds were found to be increased. Routine investigations were normal and USG Abdomen was inconclusive. CECT abdomen showed clustering of small bowel loops on the right side with bowel loops behind the SMA and SMV suggestive of right PDH. The patient was taken up for an emergency laparotomy. Intraoperatively, small bowel was seen herniating below the D3 of duodenum and clumped in the right iliac fossa. Superior mesenteric vessel was seen at the neck of the sac. A full Catell-Brasch maneuver was done to expose the neck of the sac to avoid a vascular injury and the sac was excised. An appendicectomy was done before placing a large bowel in the left hypochondrium.
Conclusion: With a high degree of suspicion and early radiological evaluation, we were able to clinch the diagnosis in the early stage. Prompt surgical intervention prevented the high morbidity and mortality associated with PDH in our patient.
Clinical significance: PDH remains an elusive diagnosis. A high degree of suspicion with early radiological evaluation is required for diagnosis. Prompt surgical intervention can prevent catastrophic outcomes associated with this condition.