Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure—a single surgeon series of 1047 cases

doi:10.1016/j.soard.2008.10.013

Surgery for Obesity and Related Diseases

Volume 5, Issue 5, September–October 2009, Pages 565-570

https://doi.org/10.1016/j.soard.2008.10.013 Get rights and content

Abstract

Background

Recent reports describing a gastric bypass technique and the need for closure at Petersen's space using an antecolic antegastric laparoscopic method have differed in the incidence of internal hernia. We report a 6.2% incidence without closure of Petersen's space in a 1047-case, single-surgeon practice.

Methods

The data from 1047 patients undergoing antecolic antegastric gastric bypass between January 2001 and December 2006 were prospectively collected and retrospectively evaluated for formation of an internal hernia at Petersen's space. All cases were performed by a single surgeon using an antecolic antegastric technique without closure of the mesenteric space and with division of 5 cm of small bowel mesentery. The biliopancreatic limb length was created at 50 cm during the first 2 years of the study and then at 50 or 100 cm depending on the patient's body mass index.

Results

Of the 1047 patients, 73 underwent laparoscopic exploration for varying degrees of abdominal pain, unexplained nausea or vomiting, or radiographic evidence of an internal hernia. Of the 73 cases, 65 were Petersen's space hernias, for an incidence of 6.2%, 7 were mesenteric enteroenterostomy hernias, for an incidence of .7%, and 1 was negative for intra-abdominal pathologic findings. A direct relationship was found between the biliopancreatic limb length and the frequency of biliopancreatic internal hernia formation (P = .0194), and a high rate of false-negative radiographic reports were noted. Subsequent to these 1047 patients, we have had no internal hernias with space closure in 339 cases.

Conclusion

Closure of Petersen's space is important in preventing the morbidity of reoperation and the incidence of internal hernia.

Section snippets

Methods

We retrospectively reviewed the charts for 1047 antecolic antegastric gastric bypass patients from a single operating surgeon (R.B.) from February 2001 to December 2006. All procedures were performed at Carolina Medical Center NorthEast (Concord, NC). The technique used remained relatively unchanged throughout the study until the frequency of internal hernias precipitated a change to routine closure of Petersen's space.

Our technique involved a 6–7-cm pouch created along the lesser curvature of

Results

Of the 1047 patients reviewed, 73 had undergone surgical intervention for abdominal pain (Table 1). The indications for surgery varied and ranged from thorough diagnostic testing and negative results, to positive CT findings, to a clinical impression only. On 16 occasions, the finding of cholelithiasis on evaluation was used as justification for cholecystectomy and concomitant diagnostic laparoscopy. Patients presenting with complaints consistent with ulcer diathesis underwent endoscopy and, if

Discussion

We have presented the data from 1047 consecutive single-surgeon antecolic antegastric gastric bypass cases that resulted in ≥65 Petersen' space hernias (6.2% incidence) when this space remained unclosed. The technique varied only in BP limb length, suggesting a significant risk of morbidity, as well as an apparent relationship between the BP limb length and the incidence of hernia formation.

We have also presented our findings regarding the different segments of small bowel entrapped in

Conclusion

As the popularity of bypass techniques increases, strict attention must be paid to eliminating the morbidity associated with internal hernia formation. After adjusting our technique to include closure of Petersen's space, we noted the absence of internal hernia occurrence in 339 cases spanning 19 months. Because the average time to presentation of an internal hernia was ≥23 months and the interval since we began closing this space has not yet reached that point, we might yet experience a

Disclosures

The authors claim no commercial associations that might be a conflict of interest in relation to this article.

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Original articleInternal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure—a single surgeon series of 1047 cases

Abstract

Background

Methods

Results

Conclusion

Section snippets

Methods

Results

Discussion

Conclusion

Disclosures

Gastroenterol Clin North Am

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Surg Obes Relat Dis

Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass

Obes Surg

Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment, and prevention

Obes Surg

Internal hernia after laparoscopic Roux-en-Y gastric bypass

Surg Obes Relat Dis

Trends in internal hernia incidence after laparoscopic Roux-en-Y gastric bypass

Obes Surg

Original article
Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure—a single surgeon series of 1047 cases