Victoria Needham, MD1, Jazmin Juarez2, Diego Camacho, MD1. 1Montefiore Medical Center, 2Albert Einstein College of Medicine
INTRODUCTION: We investigated the incidence of internal hernia (IH) in patients undergoing abdominal exploration at any interval following Roux-en-Y gastric bypass. Of patients found to have IH, we evaluated their clinical and radiographic presentations leading up to operative re-intervention, as well as the technical aspects of their initial bypass, in efforts to elucidate predictors of this bariatric morbidity.
METHODS: We used a single-institution database from 2013-2017 to conduct a review of 213 cases of abdominal exploration (diagnostic laparoscopy or exploratory laparotomy) in patients with a history of bariatric surgery.
RESULTS: 110 patients had a history of Roux-en-Y gastric bypass (11 open, 99 laparoscopic). In this group, upon operative re-exploration, 29 patients (26.1%) were found to have IH via one of the defects created by the prior bypass surgery. Of these, 15 underwent antecolic configuration of the roux limb and 11 underwent retrocolic configuration (3 unknown) at their index operation. All patients presented with abdominal pain, while physical exams ranged from mild tenderness to peritonitis. The mean white blood cell count at presentation was 9.4 (SD 3.4). 69% of patients had a CT scan with at least one finding concerning for internal hernia: swirl sign (58.6%), mesenteric edema (41.4%), free fluid (20.1%) and jejunojejunostomy (JJ) to right of midline (17.2%). 5 patients (17.2%) had a definitive small bowel obstruction diagnosed on preoperative CT scan, defined as oral contrast cutoff at a transition point in the small bowel. Of patients with an internal hernia with available operative records, 1 patient herniated through a JJ mesenteric defect not closed at initial operation, 6 via a closed JJ defect, 8 via an unclosed Petersen’s defect, 9 via a closed Petersen’s defect, and 3 via a transverse mesocolic defect. All defect closure that was performed during initial bypass surgery was noted to be done using nonabsorbable polyester sutures.
CONCLUSIONS: In our population, IH was found in over a quarter of patients who underwent abdominal exploration following Roux-en-Y gastric bypass. Abdominal pain and CT findings concerning for internal hernia appear to be valuable factors in predicting the presence of IH. However physical exam, leukocytosis and complete bowel obstruction on CT appear to be less reliable as grounds for suspicion. Closure of mesenteric defects did not appear to prevent IH, however further investigation is needed to determine the role of surgical technique in the risk of developing eventual IH.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93723
Program Number: P089
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster