Internal hernia through the Space of Peterson following bariatric surgery: Incidence, treatment, and potential cure

Andy Smith, MD, W. Borden Hooks III, MD, William W Hope, MD, James A Harris, MD, David R Miles, MD

New Hanover Regional Medical Center

The development of internal hernias following laparoscopic bariatric surgery continues to remain a perplexing and controversial problem. The purpose of this study was to evaluate our experience with internal hernias following laparoscopic gastric bypass and to further review the impact of mesenteric closure on incident rate of symptomatic internal hernias.

Following IRB approval, a retrospective review of prospective data was performed from 6/23/2003 to 4/9/2012 from a single surgeon. Demographic, operative, and outcomes data was reviewed for all bariatric patients that required surgery for an internal hernia. In 7/2005, surgical technique was changed from not closing mesenteric defects to routine closure with a running, number 2-0 permanent suture. Descriptive statistics were calculated and incidence was compared using a Χ² Test of Independence from the two groups with a p-value <0.05 considered significant.

During the study period 1107 patients underwent laparoscopic Roux-En-Y gastric bypass. There were a total of 35 patients operated on for an internal hernia for an overall incidence rate of 3.16%. At time of presentation of internal hernia, the average age was 38 with 14% being male. Average excess body weight loss was 80%. Of the 35 patients that underwent surgery, 29 were performed laparoscopically and 6 were exploratory laparotomies. All but one procedure was performed by a surgeon with advanced laparoscopic and bariatric training and one procedure was performed at an outside institution. At the time of procedure, internal hernias were reduced and the Spaces of Peterson were closed, with only one patient requiring bowel resection. Prior to routine closure of Space of Peterson mesenteric defects, the incidence of symptomatic internal hernias was significantly higher compared to the rate after routine closure (12.2% vs. 0.1%, p< 0.0001).

Internal hernias following bariatric surgery remain a small but not insignificant problem. The majority of patients can be treated successfully with laparoscopic reduction of hernia and closure of the mesenteric defect. The incidence of symptomatic internal hernias can be significantly decreased with routine mesenteric closure.

Session: Poster Presentation

Program Number: P422