Closure of Petersen’s defect in Roux-en-Y gastric bypass: anatomical landmarks and technical tips

Internal hernia is a known complication after gastric bypass, especially when performed laparoscopically. Potential internal locations include a transverse mesocolon defect; Petersen’s space, the area between the mesentery of the Roux limb and the transverse mesocolon; and a jejunojejunostomy mesenteric defect. Herewith is the description of our standard technique of routine closure of Petersen's space with 2/0 non-absorbable sutures.

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Closure of Petersen’s defect in Roux-en-Y gastric bypass: anatomical landmarks and technical tips

Authors

F Rubino, M Vix, M Simone, S Sereno, J Marescaux

Abstract

Internal hernia is a known complication after gastric bypass, especially when performed laparoscopically.
Potential internal locations include a transverse mesocolon defect; Petersen’s space, the area between the mesentery of the Roux limb and the transverse mesocolon; and a jejunojejunostomy mesenteric defect. Herewith is the description of our standard technique of routine closure of Petersen's space with 2/0 non-absorbable sutures.

Classification

tips and tricks

Keywords

Closure of Petersen’s defect, Roux-en-Y gastric bypass, anatomical landmarks, technical tips

Media type

Surgical video

Duration

03'57''

Publication

2006-09

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E-publication

WeBSurg.com, Sept 2006;6(09).
URL: http://www.websurg.com/doi-vd01en1832.htm

Closure of Petersen’s defect in Roux-en-Y gastric bypass: anatomical landmarks and technical tips

1. Anatomy 00'00''

A perfect knowledge of the anatomy is very important so as to close the Petersen’s space. Treitz and biliary limb are very important landmarks to find it.

2. Petersen’s defect 00'20''

As we see in this demonstrative case, the first thing to do is to take the biliary limb, to move it to the right, and we can see its mesentery exposed. With gentle maneuvers, the grasper is used to open the Petersen’s defect by lifting the transverse mesocolon. The Petersen’s defect can be the place and the cause for internal hernias and its perfect closure is important so as to avoid this complication. A very common mistake then is not to identify the mesentery and the transverse colon which have to be sutured together so as to close the space.

3. Suturing 01'26''

As we see in this video, omental fat comes into the place where we are putting the stitches and could be erroneously closed and leave the Petersen’s space open. A running suture should be started at the root of the mesentery and then continued cephalad towards the edge of the bowel. This is best done by driving the needle in a backward fashion. The alternative of starting the suture at the bowel edge and proceed downwards would progressively tighten the space hiding the small lower corner of the defect and leading to incomplete closure and risk of incarceration and/or strangulation. We can use a 2/0 non-absorbable suture with a preformed knot on one hand to facilitate the task. The assistant’s help is very important so as to correctly expose the transverse mesentery. Care must be taken to pass the stitches only superficially through the peritoneal layer and avoid penetration of the needle deep in the mesentery which would not strengthen the repair but only increase the risk of vascular injury.

4. Tenia coli 03'13''

In this video, we also emphasize the inclusion of the tenia coli in the last stitch of the running suture. This step, in addition to strengthening the repair ensures completeness of closure of the upper part of the Petersen’s defect. Many authors advocate prophylactic closure for all mesenteric defects during laparoscopic Roux-en-Y gastric bypass.