An internal hernia is the protrusion of an intraperitoneal viscus in a congenital or acquired foramen or retroperitoneal fossa. Paraduodenal hernias are the most common type among internal hernias and are rare causes of small-bowel obstruction. The right-sided paraduodenal hernia into the fossa of Waldeyer is less common then the left-sided one. Herein, we report a case of acute complete dynamic small-bowel obstruction leading to perforation due to a right paraduodenal hernia. Introduction Internal hernias are uncommon and the herniation occurs through a defect, which is congenital or created during previous surgery. The presentation can be varied from chronic recurrent abdominal pain to acute intestinal obstruction, and internal hernias are the cause in 5.8% of acute small-bowel obstruction.1 Electively, contrast enhanced CT is the investigation of choice while in emergency settings and diagnosis is made at laparotomy. Case presentation A fifty-five-year-old male presented to the emergency department of Pt. B.D. Sharma P.G.I.M.S. Rohtak with complaints of sudden-onset severe colicky pain in the abdomen with generalised distension for two days, vomiting for two days and inability to pass stools and flatus for two days. There was no history suggesting any chronic illness or abdominal operative procedure. On examination, the patient had tachycardia with a pulse rate of 98 per minute, his blood pressure was 130/80mm Hg, and his respiratory rate was 18 per minute. The abdomen was distended with stretched umbilicus, temperature was normal and there was no guarding or rigidity; however, the patient had tenderness all over the abdomen. The whole abdomen was tympanic and bowel sounds were increased to 6-7 per minute. The patient was resuscitated with intravenous fluids, Ryle’s tube and Foley catheter were put in and symptomatic treatment was given. Investigation revealed a raised white blood count (14000/cumm); the remaining blood profile was within normal limits. Plain abdominal X-ray (erect) showed multiple air-fluid levels [Figure1] and supine X-ray showed dilated jejunal and ileal loops [Figure2]. Ultrasonography revealed dilated bowel loops. The patient was diagnosed as a case of acute complete dynamic small-bowel obstruction and emergency laparotomy was planned. A midline laparotomy was done and retroperitoneal herniation of small bowel in the right paraduodenal region was found. The contents were reduced by gentle traction to the gut, leaving a large redundant peritoneal sac [Figure3, Figure4]. Thereafter, upon exploring the contents, a small perforation in the jejunum was noted, which was repaired with single-layer interrupted sutures. The sac was obliterated by placating the sac with catgut 2/0 sutures. The rest of the abdominal contents were found to be normal. An abdominal drain was put into the pelvis and the abdomen was closed with single-layer continuous sutures. The postoperative period was uneventful and patient was discharged on the 7 th postoperative day.
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