Laparoscopy has dramatically increased in the United States and is fast becoming the standard of care for many surgical procedures in a variety of specialties. As this technique increases in popularity, it is becoming apparent that certain complications may be more common with laparoscopy than with an open approach [1]. An example of such a complication is internal hernia after Roux-en-Y gastric bypass surgery.

We define internal hernia as herniation of small bowel through a mesenteric defect. Three potential mesenteric defects are created during a Roux-en y gastric bypass procedure (Fig. 1.). The retrocolic retrogastric approach creates transverse mesocolon, jejunojejunostomy, and Petersen’s defects, whereas the antecolic antegastric approach creates only two mesenteric defects: jejunojejunostomy and Petersen’s defect [1–3] (Figs. 2 and 3).

Fig. 1
figure 1

Potential mesenteric defects. Reprinted with permission of Schweitzer MA, et.al (2000) Laparoscopic closure of mesenteric defects after Roux-en-y gastric bypass. J Laparoendosc Adv Surg Tech 10:173–175

Full size image
Fig. 2
figure 2

Potential retrocolic retrogastric transverse mesocolon defect shown before closure at initial laparoscopic Roux-en Y gastric bypass

Full size image
Fig. 3
figure 3

Antecolic mesenteric defect (Petersen’s defect)

Full size image

Internal hernias are difficult to diagnose either clinically or with radiographic imaging. Spontaneous reduction of the hernia can occur, and patients may present with nonspecific or intermittent periumbilical pain, nausea, vomiting, anorexia, or abdominal distension [4]. Computed tomography (CT) scanning of the abdomen and pelvis and upper gastrointestinal plain radiography may be unrevealing. Diagnostic laparoscopy typically is performed to establish the diagnosis and, if possible, treat the complication.

The rate of internal hernia with use of a laparoscopic approach reportedly is 0.2% to 9% [2, 5] and generally is thought to be higher than with an open approach. This may be due to increased mobility of the viscera because of decreased scar tissue and adhesion formation, or it may result from failure to close the mesenteric defects [6, 7].

Various intraoperative measures to prevent hernias have been described in the literature. Meticulous technique, including closure of the mesenteric defects with nonabsorbable suture in a running fashion [6], proper anatomic orientation of the Roux limb [3], nondivision of small bowel mesentery [5], and use of the antecolic approach, has been advocated, but the effectiveness of the listed measures remains uncertain.

We report one surgeon’s experience with 479 laparoscopic gastric bypass procedures using both retrocolic and antecolic approaches. In all cases, mesenteric defects were closed using a running nonabsorbable suture technique. Our goal was to identify technical factors that might decrease the incidence of internal hernias and prevent this uncommon but nevertheless important complication.

Methods

We queried our bariatric surgical database from August 2001 to September 2005, capturing all laparoscopic Roux-en-Y gastric bypass procedures performed by a single surgeon at our institution. A total of 479 patients were reviewed, with documented follow-up periods ranging from 2 to 6 years. Body mass index (BMI), age, and sex were recorded, as was the occurrence of postoperative hernia. All patients met the National Institutes of Health guidelines for bariatric surgery, namely, a BMI exceeding 40 or a BMI greater than 35 with multiple comorbidities.

Two surgical techniques were used in performing the laparoscopic Roux-en-Y gastric bypass: retrocolic retrogastric (n = 274) and antecolic antegastric (n = 205) procedures. The surgeon’s operative technique was otherwise consistent. The procedure was performed through five trocars. A gastric pouch approximately 20 to 30 ml in size was created. A linear stapler was used to perform the side-by-side gastrojejunostomy, and oversewing was used to create a two-layered anastomosis. The jejunum and mesentery were divided an average of 40 to 75 cm from the ligament of Treitz (at the optimal site for least tension), and a side-by-side linear stapled jejunojejunostomy was created.

With the retrocolic retrogastric approach, the mesenteric defect was closed immediately after the anastomosis. During the antecolic antegastric approach, we changed our strategy and elected to close the mesenteric defect at the end of the case. The Roux limb (80–100 cm) was brought to the gastric pouch in a right orientation, either through a retrocolic retrogastric approach or via an antecolic antegastric approach.

All defects were closed with a nonabsorbable running suture at the time of surgery. Closure was obtained by suturing mesentery lined with visceral peritoneum and not denuded adipose tissue. Particular attention was paid to closure of Petersen’s defect from the root of the mesentery of the Roux limb and transverse colon to the transverse colon itself. We recorded the exact location of any internal hernias in patients who underwent either laparoscopic or open exploration.

In addition to describing our own experience, we conducted a literature search for articles describing internal hernias as a complication of Roux-en-Y gastric bypass surgery (Table 1). A MEDLINE search was performed from January 2003 to January 2007 using the search terms “laparoscopy,” “obesity,” and “internal hernia.” Data extracted from articles included the number of patients, the anatomic orientation of the Roux limb, the specific defects that were closed, the type of suture used to close defects, the time to the presentation of symptoms, and the incidence of internal hernias (Table 2).

Table 1 Frequency of internal hernia
Full size table
Table 2 Literature review: incidence of internal hernias after Roux-en Y gastric bypass
Full size table

Results

Of the 479 laparoscopic Roux-en-Y gastric bypasses performed at our institution, 7 internal hernias (1.5%) were documented. All 7 hernias occurred among the 274 procedures performed using the retrocolic retrogastric technique, yielding a rate of 2.6% for this particular approach (Table 1). All defects had been reapproximated at the time of the initial surgery using a nonabsorbable running suture. The locations of the hernias were as follows: two at the transverse mesocolon, one at Petersen’s defect, and four at the jejunojejunostomy (Table 3).

Table 3 Location of internal hernia
Full size table

All seven cases presented within the first postoperative year. The most common presenting symptom was abdominal pain undiagnosed after appropriate laboratory investigations and radiographs. Six patients underwent laparoscopic hernia repair and defect closure. The seventh patient required an open procedure due to extensive small bowel dilation with resultant inadequate intraabdominal workspace. No internal hernias were reported among the 205 patients who underwent surgery using the antecolic antegastric method.

An additional 35 patients underwent postoperative diagnostic laparoscopy, which found no internal herniation. This group had a mean time of 175 days (range, 2–258 days) to presentation. Of these patients, 15 were found to have cholelithiasis and subjected to laparoscopic cholecystectomy. Four of these patients were taken back in the early postoperative period for suspected bleeding, and one underwent lysis of an adhesive band. At diagnostic laparoscopy, 15 patients showed no abnormal findings.

Discussion

Laparoscopic Roux-en-Y gastric bypass currently is the most common surgical weight loss procedure in the United States. Compared with the open approach, the laparoscopic technique affords a shorter hospital stay, decreased postoperative pain, fewer wound complications, and decreased ventral hernia occurrence [1, 4]. However, the laparoscopic approach carries an increased risk of internal hernia, an uncommon but important complication. The reported incidence of internal hernia among this population ranges widely, from 0.2% to 9%. Increasing evidence suggests that technical factors related to construction of the Roux limb play an important role in determining susceptibility to this complication.

Early laparoscopic bariatric surgeons used a retrocolic retrogastric approach modeled after the open procedure. However, failure to close the mesenteric defects was associated with a high rate of hernias (3.5–5.6%) [2, 6]. Careful attention to closure of the defects led to a reported improvement in hernia incidence (0.9–4.5%) [8, 9]. Initial reports of the antecolic approach did not demonstrate a clear-cut improvement in outcome. However, this approach, without closure of Petersen’s defect, often was compared with a retrocolic approach in which all defects were closed [2, 8–11].

In our case series and literature review, we found that closure of all mesenteric defects, regardless of the technique used, decreased the rate of internal hernias. We also demonstrated a statistically significant decrease in the incidence of internal hernias using the antecolic antegastric approach compared with the retrocolic retrogastric approach. We believe that the antecolic antegastric technique provides better exposure and easier closure of the jejunojejunostomy mesenteric defect at the end of the case than creation of the anastomosis immediately afterward, as with retrocolic retrogastric technique. With this meticulous technique we have seen a lower rate of internal hernia formation.

Although we recommend use of the antecolic approach and closure of all defects with nonabsorbable running suture whenever feasible, we emphasize strongly the importance of early recognition and treatment of internal hernias. Most internal hernias occur 6 to 24 months after the operation, but occurrences as early as 1 week and as late as 3 years afterward have been described, necessitating continued vigilance on the part of the surgeon [11a]. Whereas the open gastric bypass patient with abdominal pain and complete small bowel obstruction on abdominal CT scan may be treated for presumed adhesions with bowel rest and nasogastric decompression, the laparoscopic patient should be returned to the operating room if conservative measures do not rapidly result in a resolution of symptoms.

A diagnosis of internal hernia should be considered for patients who present with recurring periumbilical, colicky abdominal pain, with or without nausea and vomiting [12]. Our approach for such patients begins with a careful history, considering both internal hernia and alternative etiologies such as infectious gastroenteritis, pregnancy, biliary tract disease, ulcers, and appendicitis. A complete blood count, beta human chorionic gonadotropin, and chemistry panel are routinely obtained. Specific imaging methods, such as right upper quadrant ultrasound and upper endoscopy, are used when appropriate, and most patients undergo abdominal CT scanning as well (Fig. 4). The accuracy of CT scanning in the diagnosis of internal hernia has not been firmly established, but reports have suggested a sensitivity of approximately 60% and a high specificity [2]. In the absence of definitive findings on imaging studies, we have a low threshold for returning to the operating room to perform diagnostic laparoscopy.

Fig. 4
figure 4

Algorithm for diagnosis of internal hernia

Full size image

In conclusion, we have found the antecolic antegastric approach, with closure of all mesenteric defects, superior to the retrocolic approach with respect to prevention of internal hernia after laparoscopic Roux-en-Y gastric bypass. We believe the advantage of this approach lies in closure of the jejunojejunostomy mesenteric defect at the conclusion of the case, which provides better exposure to the defect, permitting more meticulous closure. We recommend use of the antecolic approach with all patients for whom it is anatomically feasible.