Congenital Left Mesenteric-Parietal Hernia Associated to a Small Bowel Volvulus: About a Case

Introduction: The left mesenterico-parietal hernia or left paraduodenal hernia is an anomaly of intestinal rotation which may be responsible for intestinal obstruction. It is rare. Observation: A 5-year-old boy was admitted for abdominal pain with episodes of vomiting and cessation of matters and gases. After clinical and paraclinical investigations, the diagnosis of occlusion was accepted and the child was operated. Exploration revealed a mesenteri-co-parietal hernia with a retrocolic sac measuring 11 cm of collar and a deep of 18 cm containing a twisted bowel. After reduction of the content, we untwisted the small intestine and released adhesions. The hernial sac was partially resected and the defect was closed. Operating outcomes were simple. Conclusion: The mesenterico-parietal hernia is a cause of organic intestinal obstruction. Although of congenital origin, it can have a late clinical manife-station. It should be considered in case of episodes of repetitive abdominal pain and vomiting to avoid complications.


Introduction
The left mesentero-parietal hernia, also called left paraduodenal hernia, is an exceptional form of intestinal rotation anomalies. It is the most common type of internal abdominal hernia. It represents 50% to 55% of all intestinal hernias. In addition, 80% of them would be observed on the left side [1]. The occlusion mechanism is an intestinal fold at the hernial neck, without ischemia [2]. Most Open Journal of Pediatrics often, its clinical picture is a digestive symptomatology with a type of incomplete high occlusion usually recurrent. This symptomatology can continue during a few months, even a few years and up to childhood in certain cases thus favoring a diagnostic wandering with risks of complications. In all cases, despite the potential seriousness of these complications, the prognosis remains better due to the localized nature of intestinal ischemia. We report a case of mesenterico-parietal hernia associated with non-ischemic small bowel volvulus.

Observation
A 5-year-old boy, admitted for sudden onset of abdominal pain associated with bilious vomiting, matters and gases cessation, lasting for 4 days before his admission. In his history, he was born at term with a birth weight of 2500 g, an apgar of 10. He had since the age of 6 months episodes of abdominal bloating, crying, profuse diarrhea and food vomiting. No diagnosis was made after several medical visits to the pediatrician. In admission he a growth retardation, a good conscience, well-colored conjunctiva, hemodynamic and respiratory stability, a body weight of 14 kg, a Z score of −2, a temperature of 37.5˚C. His abdomen was distended, with a tympanism. The rectal ampoule was empty on digital rectal examination. A Plan abdominal radiograph revealed mixed-type hydro-aeric levels (small intestinal, colic) with absence of rectal air ( Figure 1). A biological assessment was carried out. The hemoglobin level was 12 g/dl, the hematocrit at 36, the white blood cells at 4000, the platelets at 150,000, the natremia at 120 mmol/L, the serum potassium at 2 mmol/L, the chloremia at 98 mmol/L and

Discussion
Peritoneal recesses are usually related to rotation of the gut and adhesion of abdominal viscera to the posterior abdominal wall during fetal development, and/or the presence of retroperitoneal vessels which raise serosal folds [3].   with the parietal peritoneum. There is also an associated abnormal rotation during imprisonment of the small intestine beneath the developing colon. These recesses, therefore, are regarded as congenital and have been considered clinically and surgically as sites for internal abdominal hernias [4]. Para duodenal hernia is the most common cause of internal hernia. It represents alone 53% of internal hernias and 75% of para-duodenal hernias [5]. The left mesenterico-parietal or paraduodenal hernia is the protrusion of the intra-abdominal viscera through the Landzert paraduodenal fossa [6]. According to some authors, they interest men three times more often than women [7] [8]. Our case was also discovered in a boy.
These hernias are difficult to diagnose clinically. Internal hernia can be asymptomatic or cause significant discomfort ranging from constant vague epigastric pain to intermittent colicky periumbilical pain [9]. Sometimes despite these meticulously performed radiologies the diagnosis remains uncertain and made intraoperatively [7] as was the case in our observation.
In an acutely ill child with midgut volvulus or obstruction, urgent operative intestine. It may be necessary to resect a sphaceled bowell [11].
The hernial opening must be closed using absorbable sutures or not. But any attempt to excise the hernial sac should be prohibited [7] [12] [13]. In our observation, the hernial sac was large enough and was partially resected.
The intestinal malrotation must be treated at the same time as in our observation. In the immediate postoperative period, the child did not face any concern. Open Journal of Pediatrics

Conclusion
Left para-duodenal hernia is a rare, but possible, cause of acute intestinal obstruction in children. This should be considered in the presence of spontaneously reduced episodes of sub-occlusion. Late diagnosis can cause complications such as loop necrosis.

Parent Consent
Due to the scientific interest of the case, the child's parents were informed and have given their consent for the publication.