Revisional bariatric surgery for internal hernia after a Roux-n-Y gastric bypass

The typical case is a patient who has undergone a Roux-n-Y gastric bypass. After losing weight these patients may present intermittent abdominal pain and distension.

The CT-Scan with oral contrast may reveal a change in the gouge of the gut, twisted mesenteric vessels, or altered progression of the oral contrast. These radiological signs confirm the diagnosis.

This video focuses on giving tips and tricks for surgical revision of patients with acute bowel occlusion due to internal herniation after a Roux-n-Y gastric bypass.

This patient was placed in the supine position with open legs, with the leading surgeon standing between the legs plus one assistant to the patient’s right. A total of 4 trocars were used:  a 5-mm trocar in a supraumbilical position for a 30º scope, a 12-mm trocar at the right iliac fossa, and two 5-mm trocars located at the left iliac fossa and the left flank.

Throughout the procedure, the surgeon must look for bowel distension and viability, identify the cause and solve it. There are two main etiologies: postoperative adhesions, and herniation through the mesenteric defects produced by the bypass (Petersen’s space or the mesenteric gap of the jejuno-jejunal anastomosis).

To maintain the anatomical orientation, the revision must be performed in a systematic manner. One approach is from the gastro-jejunal anastomosis to the ileocecal valve.

The supramesocolic area is inspected and the alimentary loop is identified.  In this case the nasogastric tube decompressed it. Traction movements must be delicate to avoid injuries to the small bowel.

Venous congestion was evident from the color of the jejunal wall and the mesenteric veins, and there was some twisting and increased traction near the jejuno-jejunal anastomosis. The hernia could not be reduced this way.

A change of strategy was required. The surgeon now performed the revision from the ileocecal valve up to the jejuno-jejunal anastomosis. The small bowel must be completely grabbed during mobilization, as partial grabbing may result in perforation.

This is the jejuno-jejunal anastomosis that is placed in its anatomical position. A portion of the common loop was herniated through the mesenteric defect. The reduction of the bowel became now feasible. The surgeon must maintain a high level of suspicion regarding unexpected injuries to prevent postoperative complications.

At some stages of the surgery the bowel may become folded on itself. To solve this, the surgeon must maintain the traction of the loop that is being reduced so as to maintain the orientation and remove the other loops with the other hand.

The reduction of the internal hernia was as follows: step by step the gut was placed in the correct position and a wide mesenteric defect was identified and closed with a running suture. The suture from the closure performed in the first surgery can be seen.

Further revisions revealed a wide defect between the alimentary limb and the mesentery of the transverse colon: this is Petersen’s defect.  It must be closed too.

In order to achieve correct exposure, the assistant surgeon performed traction of the transverse colon.  A running suture accomplished this final step of the surgery.