IPEG 2020 Top Abstract: Laparoscopic Left Mesocolic Hernia Repair

We present a case of a laparoscopic repair of a left mesocolic hernia in a pediatric patient. A 15 year old male presented with sudden acute lower abdominal pain and bilious vomiting with a history of chronic abdominal pain. Here a CT shows the inferior mesenteric vein with bowel loops passing under it and indenting the stomach, concerning for a left mesocholic hernia. A left mesocolic hernia, also known as a left paraduodenal hernia, is an internal hernia defect under the inferior mesenteric vein and through the left colon mesentery. Common presenting symptoms are acute and chronic abdominal pain, vomiting, and other obstructive symptoms. He was taken to the operating room, and 3 ports were inserted as shown. The bowel was run from the terminal ileum proximally, and a hernia in the left colon mesentery containing small bowel was noted. The bowel was decompressed distally and mildly dilated proximally. There was a significant amount of bowel in the hernia that was reduced. You can see the bowel loops coming out from under the colon mesentery as the bowel is reduced. The bowel becomes more tethered as we approach the ligament of trites. Once the bowel had been reduced out of the left mesocolic hernia, the inside of the hernia sac was examined. The ligament of trites was noted. The tissue overlying the anterior aspect of the medial mesocolic hernia sac was open. The inferior mesenteric vein was mobilized away from the hernia sac. The left ureter was noted peristalsing in the retroperitoneum in the posterior aspect of the hernia sac. The peritoneum adjacent to the vein, was sutured to the jejunum and posterior peritoneum to close the neck of the sac. Tissue inferior to the ureter was used to close the sac. Once the end of the silk suture was secured, it was used in a running fashion to close the lateral aspect of the defect, taking care with each bite to avoid injury to the ureter. After closure of the lateral aspect, the medial aspect was closed with interrupted seromuscular bites of jejunum. Care was taken with each bite to again avoid injuring the inferior mesenteric vein. The hernia sac appeared adequately closed. He was discharged home 36 hours after his surgery completed, no longer having intermittent abdominal pain. In a recent review of all previously reported cases of mesocolic hernias, 70% were left sided, while 30% were right sided. Only about 30% of reported cases were completed laparoscopically, while there are analyses showing decreased morbidity and length of stay with the laparoscopic approach. Although congenital, most patients present as adults. In conclusion, laparoscopic left mesocolic hernia repair can be safely and effectively performed in pediatric patients. Thank you.