Laparoscopic Treatment for Bowel Obstruction After Gastric By-pass

Introduction
Internal hernias are a common and often misdiagnosed complication that may occur after Roux-en-Y anastomosis. It may be at the origin of small bowel ischemia and necrosis. This video shows a typical example of such a complication.
Method
A 23-year-old woman who had undergone a gastric bypass procedure for morbid obesity 2 years ago presented to the emergencies complaining of postprandial abdominal pain. She was not vomiting and her bowel movements were preserved. Her BMI was 29, with a weight loss of 45 Kg over 23 months (initial BMI 44). Clinical exam and biological findings were unremarkable: normal white cell count, and no inflammatory reaction. The CT-scan did not show any bowel dilatation or indirect signs of obstruction.
Although the patient felt better during the first twelve hours of nothing per os, the decision was made to perform a laparoscopic exploration in order to explore the bowel and the Petersen’s space. This exploration showed an internal Petersen’s hernia with a venous congestion of the alimentary limb. All of the distal bowel had gone through the Petersen’s defect.
During the first operation, the Petersen’s space was closed with a monofilament non-absorbable suture: a residual suture was found on the margin of the internal hernia defect. The bowel was fully explored and there was no sign of trauma that would induce pain. The Petersen’s space was re-approximated, using a non-absorbable braided running suture. The postoperative course was uneventful.
Conclusion
This case demonstrates the benefit of a systematic surgical exploration after gastric bypass in the case of postprandial abdominal pain. Indeed, with or without vomiting, and even with a normal CT-scan, this procedure should be performed. It also demonstrates that the closure of the Petersen’s defect with monofilament non-absorbable suture does not systematically prevent internal hernias.


Session: Podium Video Presentation

Program Number: V006

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