Fossa Of Landzert Herniation In A Young Woman Presenting With Chronic Episodic Abdominal Pain

INTRODUCTION: Multiple aberrations evolve during the formation of the mesentery in the stages of early development. These aberrations from gut malrotations may lead to fossa development where bowel loops may herniate. Herein we present a case of a left mesocolic paraduodenal hernia into a dorsal mesentery fossa also called the Fossa of Landzert. CASE DESCRIPTION/METHODS: A 20-year-old female who presented to the Gastroenterology clinic with long term complaints of episodic abdominal pain, nausea and vomiting. She had been evaluated by various health care providers with extensive work-up including multiple imaging studies such as abdominal Ultrasonography, CT scans and esophagogastroduodenoscopy with biopsies without detection of clear pathology. Abdominal examination revealed mild epigastric tenderness to palpation, without distention or peritoneal signs. CT scan showed a cluster of bowel loops above the celiac artery (Image 1) which prompted suspicion for a supra mesocolic hernia without obstruction. She was referred to a surgeon for direct visualization using robotic-assisted diagnostic laparoscopy. Intraoperative findings revealed herniation of the majority of her small bowel with the exception of about 10 cm of the terminal ileum through the paraduodenal fossa up to the transverse mesocolon into the lesser space behind the stomach. Reduction and repair of paraduodenal hernia with closure of mesenteric defect was performed successfully. She was discharged four days later with complete resolution of symptoms. DISCUSSION: The fossa of Landzert is located behind the ascending part of duodenum. Herniations occurs when small bowel loops prolapses through the Landzert fossa. This is present about 2% of the population. Paraduodenal hernias occur both on the right and left side, with left sided hernias being more common than right. Symptoms of episodic nausea, vomiting and intermittent cramping the absence of imaging findings should trigger suspicion of paraduodenal hernias.CT has been shown to have good specificity with detection of para duodenal hernias but definitive diagnosis and treatment involves exploratory laparoscopy to further visualize and repair these hernias. Timely treatment with surgical intervention is important due to risk of bowel incarceration and death, Hence it is important for clinicians to have a high index of suspicion for paraduodenal hernias with patients presenting with nonspecific radiologic findings and clinical symptoms.Figure 1.: Abdominal CT scan with a cluster of bowel loops above the celiac artery.