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Left paraduodenal hernia: a rare cause of small bowel obstruction in the elderly. Left paraduodenal hernia is a rarely found condition in which the small bowel herniates through a congenital peritoneal defect located behind the 4th portion of duodenum. It usually courses with non-specific symptoms and a widely variable clinical presentation which makes preoperative diagnosis very difficult. It has been associated with a high rate of complications, including bowel strangulation and even death. Prompt surgical intervention consisting of intraoperative surgeon's awareness and recognition of this condition are crucial in order to improve postoperative morbidity and mortality. The authors present a case of a 73-year-old man with acute intestinal obstruction as the first presentation of a left paraduodenal hernia.