Left paraduodenal hernia with retrograde intussusception

A 38-year-old male presented with abdominal pain, vomiting, and inability to pass stool or flatus for 1 day, with tenderness in the left upper quadrant. Computed tomography (CT) of the abdomen showed a cluster of dilated jejunal loops (maximum diameter 3.6 cm) with normal wall thickness and enhancement in the left anterior para-renal space, posterior to the ascending branch of the left colic artery (Fig. 1). A proximal jejunal loop protruded into the third and fourth parts of the duodenum, creating a filling defect (Fig. 2). The loss of free flow of oral contrast beyond the fourth part of the duodenum indicated an obstruction. The diagnosis was a left paraduodenal hernia with retrograde jejuno-duodenal intussusception, with the fourth part of the duodenum serving as the intussuscipiens and the jejunum as the intussusceptum. The length of the intussusception was approximately 3 cm. An exploratory laparotomy was done with reduction of herniated bowel loops and hernia closure. The intussusception had reduced spontaneously before surgery.

FIG 1. Contrast computed tomography (CT) abdomen images showing relation of left paraduodenal hernia (yellow arrows indicates herniated intestinal loop) with respect to left colic artery (red arrow) in coronal sections (a) and ascending branch of left colic artery (red arrow) in sagittal (b) sections

FIG 2. Contrast computed tomography (CT) abdomen images showing left paraduodenal hernia (yellow arrows indicate herniated intestinal loop) alongside retrograde intussusception (red arrow) in non-contrast axial (a) and contrast coronal sections (b)

Paraduodenal hernias are the most common type of internal hernias.¹ Left paraduodenal hernias originate from the Landzert fossa, located to the left of the fourth part of the duodenum, posterior to the ascending branch of the left colic artery.² Intussusception can be antegrade or retrograde, with the latter involving the distal segment folding into the proximal intestine.³ Retrograde intussusception is thought to result from reverse peristalsis due to distal obstruction.⁴ It resolves spontaneously if shorter than 3.5 cm.⁵

Left paraduodenal hernia with retrograde intussusception is rare, has a non-specific presentation, can be diagnosed by contrast-enhanced CT, and is treated by bowel reduction and closure of the hernia defect.