Laparoscopic management of an internal hernia in a pregnant woman with Roux-en-Y gastric bypass.

Management of abdominal pain in a pregnant patient with a history of Roux-en-Y gastric bypass presents unique challenges. A misdiagnosis or delay in management can result in lethal maternal-fetal outcomes. We present a 30-year-old woman at 21 weeks of pregnancy presented with abdominal pain. She had a history of laparoscopic Roux-en-Y gastric bypass performed 3 years earlier. The clinical examination was remarkable for epigastric pain and tenderness. The vital signs and laboratory examinations were unremarkable. The CT scan was suggestive of an internal hernia. On an exploratory laparoscopy, the distal common small bowel was found to be herniating through the jejunojejunostomy mesenteric defect, causing intestinal obstruction with dilatation of the Roux limb and the biliopancreatic limb. The internal hernia was reduced, and no bowel resection was required. The mesenteric defect was closed with 3-0 silk sutures in a continuous fashion. The patient was discharged after 3 days and delivered a healthy baby at 40 weeks of gestation.

Impact of complete mesenteric closure on small bowel obstruction and internal mesenteric hernia after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Although it is generally accepted that closure of mesenteric defects after laparoscopic Roux-en-Y gastric bypass (LRYGB) reduces the incidence of small bowel obstruction (SBO), data supporting this belief are inconsistent. After a spike in acute SBO cases in our LRYGB patients, we changed our technique of mesenteric closure. The objective of this study was to determine whether modification of our technique of mesenteric closure would decrease the incidence of SBO and internal hernia after LRYGB. METHODS: The records of 872 consecutive patients who had antecolic LRYGB by 1 surgeon over a 9-year interval were reviewed for acute SBO. The first 654 patients, mean follow up = 100±12 months, had incomplete mesenteric closure versus complete closure in 218 remaining patients, mean follow up = 40±14 months. Minimum follow up was 1 year. RESULTS: Total incidence of acute SBO was 4.0% (35/872), including 4.4% (29/654) in the incomplete closure group versus 2.8% (6/218) in the complete closure patients. Seventeen (2.6%) of the incomplete closure patients with acute SBO had internal hernias versus 1 (.5%) in the complete closure group. Twenty-six patients with incomplete closure developed symptoms of SBO and subsequently had elective repair of mesenteric hernias versus none in complete closure group (P<.02). Postoperative morbidity and mortality rates after surgery for SBO were 30% and 7.4% in incomplete group versus zero in patients with complete closure. CONCLUSION: Complete closure of mesenteric defects in antecolic LRYGB resulted in a significant reduction in internal mesenteric hernias. Complications were also reduced after operations for SBO in patients who had complete mesenteric closure.