Obesity Surgery, 17, 1283-1286
Internal Hernia as a Complication of Laparoscopic Roux-en-Y Gastric Bypass Antonio Iannelli, MD; Massimo Senni Buratti, MD; Sebastian Novellas, MD1; Moucef Dahman, MD; Imed Ben Amor, MD; Eric Sejor, MD; Enrico Facchiano, MD; Pietro Addeo, MD; Jean Gugenheim, MD Université de Nice-Sophia-Antipolis, Faculté de Médecine, Nice, F-06107, France; Centre Hospitalier Universitaire de Nice, Pôle Digestif, Nice, F-06202, France; Service de Chirurgie Digestive et Centre de Transplantation Hépatique; 1Service d’Imagerie Médicale. Background: Internal hernia (IH) is a well known complication of Roux-en-Y gastric bypass (RYGBP) which is more frequently encountered when the RYGBP is done laparoscopically. Methods: Patients with IH were identified from a prospective data-base of morbidly obese patients undergoing bariatric surgery at our center. Results: 10 patients with IH were identified out of 625 patients undergoing LRYGBP from 1998 to 2006 (incidence 1.6 %). The defects were closed in the last 155 cases with non-absorbable running sutures. There were 8 women and 2 men with mean age 38 years (range 2854). The mean interval of time elapsed between LRYGBP and clinical presentation of IH was 26.5 months (range 7 days - 72 months). Abdominal pain, nausea and vomiting were the most common complaints. White blood cell count was increased to a mean of 64 mg/dl (range 45-155 mg/dl) in 6 patients. CT scan showed signs of intestinal obstruction in all 7 patients with acute presentation. Surgery was done by laparoscopy in 5 cases (2 in the setting of emergency), and by laparotomy in the remaining 5 cases. All IHs were located at the mesenteric defect and were treated with IH reduction in all but one patient who underwent small bowel resection. There was no mortality, and one patient had pneumonia with acute respiratory distress syndrome that resolved favorably. Conclusions: IH after LRYGBP occurred mainly at the mesenteric defect and in patients with no closure of the defect. The antecolic approach for the Roux-limb, the division of the greater omentum only when too thick, and the systematic closure of the defects with tight non-absorbable running sutures are recommended.
Correspondence to: Dr. Antonio Iannelli, Service de Chirurgie Digestive et Transplantation Hépatique, Hôpital Archet, 151 Route Saint-Antoine de Ginestière BP 3079, Nice, Cedex 3, France., E-mail:
[email protected] © Springer Science + Business Media, Inc.
Key words: Laproscopic Roux-en-Y gastric bypass, internal hernia, small bowel obstruction, bariatric surgery
Introduction Obesity represents a major health problem worldwide1, 2 and is associated with several major co-morbidities.3-5 Bariatric surgery is the only effective treatment for morbid obesity, given the high failure rate of non-surgical means such as exercise, diet, behavioral, and pharmaceutical management.6 Roux-en-Y gastric bypass (RYGBP) is considered by several surgeons as the gold standard of bariatric surgery7-10 because it results in a weight loss of 60% to 70% at 10 years follow-up and longer.8, 11,12 The laparoscopic (L) RYGBP has several advantages over the open RYGBP in terms of reduced perioperative complications, shorter hospital stay and a more rapid recovery,8, 13 with short- and medium-term results of weight loss similar to those obtained with the open approach.13 For these reasons, the RYGBP is now mostly performed laparoscopically.14 On the other hand, LRYGBP appears to be associated with a relatively high incidence of internal hernias (IHs), when compared to the open RYGBP.15, 16 This seems to be related to the reduced formation of postoperative adhesions following laparoscopy.16, 18 Nevertheless, the issue of closing the potential site of IH is still a matter of debate among surgeons. Herein we report a series of patients with IH occurring after Obesity Surgery, 17, 2007
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LRYGBP performed at our center and discuss the relative diagnostic and therapeutic implications.
Methods Data were retrospectively analyzed from a prospectively collected data-base at our institution for morbidly obese patients undergoing bariatric surgery, and included: age; gender; interval of time elapsed between the LRYGBP and IH; BMI (at time of LRYGBP as well as at time of IH); weight loss; previous bariatric procedures; type of clinical presentation (acute versus chronic); symptoms and signs; laboratory findings (white blood cell count, C-reactive protein); contribution of imaging to the diagnosis; closure of defects at time of RYGBP; surgical treatment (laparotomy versus laparoscopy, localization of the IH, reduction of the IH and defect repair with or without bowel resection, associated procedures); postoperative complications; mortality. LRYGBP was defined as a procedure that was attempted and completed laparoscopically. Patients undergoing either open RYGBP or conversion to open RYGBP were excluded. Relevant surgical technique details of the standard laparoscopic technique for LRYGBP adopted at our center include: the ad hoc division of the greater omentum when too thick; the division of the small bowel at 50 cm from the ligament of Treitz without division of the mesentery; the positioning of Rouxen-Y antecolic and right-oriented (with the cut end of the bowel pointing the greater curvature of the stomach;19, 20 the closure of the mesenteric defect of the Roux-en-Y loop with non-absorbable running sutures (only in the last 155 cases).
Results Ten patients (8 women and 2 men) with a mean age of 38 years (range 28-54 years) out of 625 patients undergoing LRYGBP developed an IH (incidence 1.6%) at a mean interval after LRYGBP of 26.5 months (range 7 days – 72 months). The mean preoperative BMI was 41 kg/m2 (range 37-47 kg/m2) and 26.7 kg/m2 ( range 21-45 kg/m2) at the time of 1284
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LRYGBP and presentation of IH, respectively. Seven patients (70%) presented as abdominal emergencies complaining of diffuse abdominal pain, nausea, vomiting. White blood cell count was increased (>12000 leucocytes/dL) in 4 patients. C-reactive protein was increased in 6 cases (mean 64 mg/dL; range 45-155 mg/dL). All 7 patients had intestinal obstruction as shown on CT scan and underwent surgery in the setting of emergency. Surgery was started laparoscopically in 4 cases and converted to open surgery in 2 cases because of technical difficulties. In the remaining 3 cases, patients underwent laparotomy, as the operating surgeon was not experienced in laparoscopic bariatric surgery. Surgery consisted of hernia reduction and closure of the mesenteric defect in all but one patient for whom the herniated segment of bowel had to be resected. Three patients (30%) presented as out-patients complaining of colicky abdominal pain in the left abdominal quadrants. Laboratory findings were normal. CT scan was interpreted as normal in all 3 cases before surgery. The 3 elective procedures were completed laparoscopically, and one patient also underwent cholecystectomy. In all the cases, the IH was found at the Roux-en-Y loop mesenteric defect, which was closed with a non-absorbable running suture. There was no mortality. One patient developed pneumonia due to Streptococcus pneumoniae infection with acute respiratory insufficiency on postoperative day 1 necessitating prolonged respiratory assistance. Mean length of stay was 6.9 days (range 3-20 days) respectively.
Discussion In a recent review of all cases of LRYGBPs in the literature between 1995 and 2005, we found that the IH occurred with a mean incidence of 2.5% at a mean follow-up of about 2 years.19 IHs occur more frequently after the LRYGBP compared with the open procedure, probably due to the reduced formation of postoperative adhesions following laparoscopy,19 and are the most common cause of small bowel obstruction after LRYGBP in most series.21, 22 Anatomic changes that follow the fashioning of any Roux-en-Y loop that is taken to the upper mesocolic area include two potential sites of IH, the first at the
Internal Hernia and LRYGBP
entero-enterostomy site and the second at the opening between the mesocolon and the jejunal mesentery. The latter is also known as the Petersen’s space.19, 23 The third site, the window in the transverse colon mesentery, can be avoided by placing the Roux-en-Y loop antecolic. This simple technical detail eliminates the most common hernia site responsible for about two-thirds of the IH cases reported in the literature.19 In our series, the incidence of IH was 1.6% and the mesenteric defect of the Roux loop was the only potential site involved. The low incidence of IH of our series may be explained by the antecolic position of the Roux-enY loop, its orientation (right-oriented),20 and the fact that the small bowel mesentery is not divided, avoiding a resultant window in the mesentery. The surgical technique at our center do not include systematic division of the greater omentum which is done only when the greater omentum is too thick and would cause increased tension on the gastro-jejunostomy. Thus, the course over the greater omentum may lower the incidence of IH in the Petersen space. In the present series, one case of IH was recorded in the immediate postoperative period after the introduction of the systematic closure of the mesenteric defect. At exploratory laparoscopy, the suture of the mesenteric defect was associated with an incomplete closure of the defect due to a partial tear of the mesenteric sutures. The systematic closure of the mesenteric defects may not be followed by the total disappearance of the IHs.16, 17, 22, 24 The expansion of potential IH sites that follows the decrease in intra-abdominal fat after the LRYGBP weight loss, and the tear of the mesentery at the level of the sutures that close the defect are the most common mechanisms involved in the occurrence of IHs despite the closure of the defects.19 The sutures must me done carefully with large bites and several passages close to each other, to avoid incomplete closure, hematoma formation in the mesentery or a tear of the mesentery at the level of the sutures. Clinical presentation of IH ranges from very vague and intermittent symptoms such as pain in the left abdomen associated with nausea and vomiting to dramatic acute abdomen secondary to small bowel necrosis or perforation.15, 17, 18, 20, 22 Laboratory findings are of little value and indicate the degree of bowel distress. Three patients in our series complained of crampy abdominal pain in the left abdominal quadrants and the diagnosis of IH was confirmed
only at time of laparoscopy, as CT scan had not been conclusive. The remaining 7 patients presented as abdominal emergencies with intestinal obstruction and progressive signs of acute abdomen. CT scan showed signs of intestinal obstruction without establishing the exact diagnosis of IH at the level of the mesenteric defect. In one case, the surgical team was alerted 3 days after admission and the clinical picture evolved toward intestinal necrosis necessitating a small bowel resection. Surgical treatment consisted of hernia reduction and defect closure in 9 cases in our series, and was achieved laparoscopically in only 2 patients presenting as abdominal emergencies and in all 3 patients undergoing elective laparoscopy. Laparoscopy may be challenging in patients with intestinal obstruction and the reduction of the IH may be difficult to achieve. If the surgeon has no hands-on experience in laparoscopic and bariatric surgery, conversion to open surgery is advised. On the other hand, in the case of patients with chronic signs of IH, laparoscopic treatment is the rule. We recently reported a mean time of presentation of IH of 2 years.19 However, in our series we observed the occurrence of IH from 8 days after surgery up to 6 years. Although most of IHs occur within 2 years after LRYGBP, any patient with the mesenteric defect left open may develop IH at any time. Our current policy is to close the potential hernia sites not only at the time of the LRYGBP but also in patients with past LRYGBP that shows open mesenteric defects when they undergo other abdominal procedures.22 We recommend the antecolic approach with the Roux-limb “right oriented”, the division of the greater omentum only when too thick, and systematic closure the defects with tight non-absorbable running sutures. Laparoscopic exploration is advised in patients with LRYGBP and otherwise unexplained abdominal pain even in the presence of normal laboratory and radiological findings. In the presence of intestinal obstruction in patients with LRYGBP, IH is the most probable diagnosis. In this case, surgical treatment may be possible by laparoscopy but only in experienced hands.
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