GIANT RIGHT PARADUODENAL HERNIA WITH INCARCERATION OF THE ENTIRE SMALL BOWEL: A RARE CAUSE OF SMALL BOWEL OBSTRUCTION IN A VIRGIN ABDOMEN. A CASE REPORT

Introduction: Internal hernias are protrusions of abdominal viscera through a peritoneal or mesenteric aperture within the abdominal cavity. They account for 0.5–5.8% of intestinal obstructions. Paraduodenal hernias are the classic congenital type, and incarceration of the entire small bowel within the hernia sac is exceptional.
Case presentation: We report the case of a 40-year-old man with no past medical or surgical history who presented with a three-month history of postprandial vomiting and early satiety, progressing to intractable vomiting with cessation of stool and flatus. Examination revealed mild abdominal distension and an empty rectum; laboratory tests were unremarkable. The plain abdominal radiograph showed multiple air-fluid levels, and computed tomography showed small bowel dilatation up to 4 cm, initially attributed to a congenital band. As the patient did not improve after 24 hours of conservative management, a midline laparotomy was performed. Exploration revealed a giant right paraduodenal hernia whose sac contained the entire small bowel. The loops were released by meticulous dissection and were found viable, so no resection was needed; the sac was excised. The postoperative course was uneventful and the patient was discharged on postoperative day 4. At two months, he remained free of vomiting.
Conclusion: Paraduodenal hernia should be considered in any small bowel obstruction occurring in a virgin abdomen. Because the preoperative diagnosis remains difficult, timely surgical exploration is essential to prevent strangulation and preserve bowel length.