Left paraduodenal recess hernia causing small bowel obstruction with intraoperative ventricular fibrillation: a case report

Introduction and importance: Internal hernias are a rare cause of small bowel blockages in less than 1% of patients. Paraduodenal hernias are the most common internal hernia but can be challenging to identify because presentation is nonspecific. Timely detection with early surgical intervention is essential as delayed diagnosis can lead to strangulation, ischemia, and ultimately mortality. Case presentation: We present a challenging case of a small bowel obstruction due to a paraduodenal hernia in a 74-year-old man with multiple comorbidities that was complicated intraoperatively by ventricular fibrillation (VF) requiring cardiopulmonary resuscitation and defibrillation. Following clinical assessment, imaging workup raised the possibility of internal hernia. After initial resuscitation, exploratory laparotomy was performed and found to have viable jejunal loop incarcerated in the left paraduodenal recess with impending risk of strangulation. Adhesiolysis, release of bowel contents, and repair of the hernia sac were performed. Intraoperative cardiac arrhythmia (VF) was successfully managed by the anesthesia team. Following surgery, patient was managed with intensive care and other supportive measures and ultimately discharged after full recovery. Clinical discussion: Paraduodenal hernias are embryological defects resulting from midgut malrotation. The clinical spectrum of presentation is variable. Patients may complain of intermittent abdominal pain or present with an acute intestinal obstruction. A contrast enhanced computed tomography scan is the preferred diagnostic imaging modality to assess the small bowel, and it may show loops of small bowel that are encapsulated in the paraduodenal recess. If recognized early, surgery is the only definitive management and can be performed through an open technique or laparoscopic approach. Prompt surgical intervention is important as the morbidity related to paraduodenal hernias can be minimized, and since recurrence can occur. Conclusion: This case illustrates the significance of weighing paraduodenal hernia as a differential diagnosis in small bowel obstruction. It is significant, as it again illustrates that a rare, yet critical diagnosis can be overlooked, specifically in the resource-limited circumstances. The report reaffirms that early recognition through clinical suspicion supported by imaging, followed by timely surgical intervention with careful consideration of comorbidities, is essential to achieving better patient outcomes. The take-home lessons for clinical practice and learning points include always have a high suspicion for internal hernia, recognition of the importance of imaging to allow early diagnosis and provide timely surgical intervention to avoid bowel ischemia and its complications.