Alph Emmanuel, MD, S. Julie-Ann Lloyd, MD, PhD, Bestoun H Ahmed, MD, FACS, FASMBS. University of Pittsburgh Medical Center, PA
Small bowel obstruction following laparoscopic Roux-en-Y gastric bypass surgery is an uncommon complication with reported incidence of 1.5 to 5 %. The most common causes are internal hernia, roux limb stricture and adhesions causing 89% of cases. In our patient, the cause of the bowel obstruction was rare and unusual.
Our patient is a 33 yr old female who underwent robotic assisted laparoscopic antecolic, antegastric Roux-en-Y gastric bypass. The gastrojejunostomy and jejunojejunostomy were created using a linear stapler with the enterotomy closed using barbed suture. Both mesenteric defects were closed. Patient presented 3 weeks after surgery with nausea, vomiting and abdominal pain. CT scan showed, moderately dilated excluded stomach and BP limb with dilated loops of small bowel adjacent to the JJ anastomosis, there was a band like narrowing suggestive of obstruction. No internal hernia was seen.
Patient was taken to the operating room for laparoscopic exploration. The excluded stomach and BP limb were dilated. The JJ anastomosis was patent with a suture tail extending from the anastomosis to an adjacent loop of small bowel. There was a separate loop of small bowel that was caught under this suture tail causing acute narrowing of the lumen. The suture tail was cut with immediate decompression of the dilated proximal bowel. Bowel resection was not required. There was no internal hernia.
There are few reports of the free end of barbed suture causing a small bowel obstruction. Most of the reports in published literature are in colorectal and gynecological surgery. There are a few reports of similar incidents during closure of the peritoneum in trans-abdominal pre-peritoneal inguinal hernia surgery. There was only one published paper about a similar complication after laparoscopic Roux-en-Y gastric bypass surgery.
Barbed suture is commonly used in complex laparoscopic surgery because it decreases operative time without increase in complications. However, leaving a suture tail can lead to small bowel obstructions. We recommend taking a few extra bites in the tissue after closing the enterotomy to allow the suture tail to be buried. The suture then cut flush with the bowel wall without placing the knot. We have not had any similar complications after introducing this technique in our practice.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93414
Program Number: V228
Presentation Session: Video Loop Day 2
Presentation Type: VideoLoop
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