Internal hernia after laparoscopic Roux-en-Y gastric bypass

Internal hernia following laparoscopic RYGBP is a rare but potentially fatal complication. This is the case of a 40-year-old patient who benefited of a gastric bypass for morbid obesity. She had a BMI of 50. She presented with post-prandial pain associated with vomiting. The gastroscopy showed no abnormality. The contrast swallow and follow-through examination showed a stenosis 30cm from the gastrojejunal anastomosis with an almost complete obstruction. This finding was corroborated by the CT-scan, which identified an internal passage at the level of the alimentary loop. The laparoscopic repair of this internal hernia is presented.

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Internal hernia after laparoscopic Roux-en-Y gastric bypass

Authors

F Costantino, J Marescaux

Abstract

Internal hernia following laparoscopic RYGBP is a rare but potentially fatal complication. This is the case of a 40-year-old patient who benefited of a gastric bypass for morbid obesity. She had a BMI of 50. She presented with post-prandial pain associated with vomiting. The gastroscopy showed no abnormality. The contrast swallow and follow-through examination showed a stenosis 30cm from the gastrojejunal anastomosis with an almost complete obstruction. This finding was corroborated by the CT-scan, which identified an internal passage at the level of the alimentary loop. The laparoscopic repair of this internal hernia is presented.

Classification

clinical cases

Keywords

Internal hernia, laparoscopic Roux-en-Y gastric bypass, RYGBP

Media type

Surgical video

Duration

07'23''

Publication

2010-01

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E-publication

WeBSurg.com, Jan 2010;10(01).
URL: http://www.websurg.com/doi-vd01en2675.htm

Internal hernia after laparoscopic Roux-en-Y gastric bypass

1. Introduction 00'11''

This video aims at demonstrating the laparoscopic repair of an internal hernia following a laparoscopic Roux-en-Y gastric bypass.

2. Clinical case presentation 00'19''

This is the case of a 40-year-old patient who benefited of a gastric bypass for morbid obesity. She had a BMI of 50. She presented with postprandial pain associated with vomiting. The gastroscopy showed no abnormality. The contrast swallow and follow-through examination showed a stenosis 30cm from the gastrojejunal anastomosis with an almost complete obstruction. This finding was corroborated by the CT-scan, which identified an internal passage at the level of the alimentary loop. The patient’s weight loss had proven satisfactory. However, faced with persistent abdominal pain, a laparoscopic exploration was decided upon. Here a 10-12mm camera is introduced via a mini-laparotomy, two 5mm trocars are introduced and an exploration of the abdominal cavity is carried out.

3. Laparoscopic exploration 01'19''

Here we can observe the presence of adhesions both at the level of the alimentary loop as well as at the foot of the loop. Of note, distension in the mesocolic region can be seen as indicated by the preoperative check-up. The exploration is started from the common loop of bowel at the level of the ileocaecal valve. Its objective is to bring the common loop cephalad and identify the Roux-en-Y anastomosis at the foot of the loop. You can now observe that the small bowel is not distended at the level of the common loop as demonstrated by a process at the submesocolic region.

4. Identification and marking of common loop 02'35''

The common loop is clearly identified at the level of the anastomosis at the foot of the loop. Posteriorly to it, the presence of an abnormal passage may be seen. The common loop is marked and we follow the path of the alimentary loop cranially. An adhesion is clearly visible between the alimentary loop and the anastomosis at the foot of the loop.

5. Biliary loop exploration 03'24''

We then decide to explore the entire biliary loop, which is in an orthotopic position. We then can make sure that the Petersen’s space is closed, thus the risk of occlusion is ruled out. The small bowel loops, including the biliary loop, are not distended, hence demonstrating the patency of the anastomosis at the foot of the loop.

6. Identification of internal hernia 04'00''

Here you can observe the path of this internal hernia situated between the anastomosis at the foot of the loop and the alimentary loop. At this moment, it is observed that the path of this loop corresponds to the alimentary loop and we can perform the introduction from the latter. This biliary loop will go through the defect between the lateral aspect of the biliary loop and the anastomosis at the foot of the loop. This band is caused by the inflammatory tissue that might have formed following the anastomosis that was performed at the foot of the loop.

7. Adhesion dissection 04'40''

This adhesion or band is excised using monopolar cautery scissors. Dissection is performed smoothly without any kind of bowel resection since there is no vascular anomaly. Complete mobilization of this adhesion is achieved and we can complete the freeing of this opening. Here you can observe how the alimentary loop remains detached from its previous attachments. Here the alimentary loop is landmarked once it has been reduced of its internal hernial orifice.

8. Closure of mesenteric defect 06'00''

At this moment, we decide to close the mesenteric defect. Here you can see the duodenal loop lifted by the grasper and the anastomotic defect is closed. Of note, the mesenteric defect is closed using a non-absorbable monofilament 3/0 running suture. This defect was opened during surgery following the freeing of the band that had formed between the bowel loop and the foot of the anastomosis. The patient’s postoperative outcome is uneventful. The patient resumed food intake on postoperative day 1. No postoperative pain was observed.