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9. Rosenthal RJ, International Sleeve Gastrectomy Expert Panel, Aceves Diaz A, et al.
International Sleeve Gastrectomy Expert Panel Consensus Statement: best practice guidelines
based on experience of >12,000 cases. Surg Obes Relat Dis. 2012;8(1):8–19.
10. Al-Kurd A, Grinbaum R, Abubeih A, Verbner A, Kupietzky A, Mizrahi I, Mazeh H, Beglaibter
N.Not all leaks are created equal: a comparison between leaks after sleeve gastrectomy and
Roux-En-Y gastric bypass. Obes Surg. 2018;28(12):3775–82.
11. Iossa A, Abdelgawad M, Watkins BM, Silecchia G.Leaks after laparoscopic sleeve gastrectomy: overview of pathogenesis and risk factors. Langenbecks Arch Surg. 2016;401(6):757–66.
12. Enochs P.Leaks and single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI).
Bariatric Times. 2020;17(6):20–1.
13. Court I, Wilson A, Benotti P, Szomstein S, Rosenthal RJ.T-tube gastrostomy as a novel
approach for distal staple line disruption after sleeve gastrectomy for morbid obesity: case
report and review of the literature. Obes Surg. 2010;20(4):519–22.
14. Leeds S, Ward M.Management of the contained leak. Bariatric Times. 2020;17(4):9–11.
15. Nguyen D, Dip F, Hendricks L, Lo Menzo E, Szomstein S, Rosenthal R.The surgical management of complex stulas after sleeve gastrectomy. Obes Surg. 2015;26(2):245–50.
16. Nedelcu M, Danan M, Noel P, Gagner M, Nedelcu A, Carandina S. Surgical management
for chronic leak following sleeve gastrectomy: review of literature. Surg Obes Relat Dis.
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17. de Tudela AC, Vilallonga R, Ruiz-Úcar E, Pasquier J, Del Castillo JMB, Nedelcu A, Fort JM,
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Chapter 49
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Internal Hernias andBowell Obstruction
AdmarConconFilho, LaisaSimakawaJimenes, StephanieKilarisGallani,
andMarinaAndradeMacedoPacettiMiranda
49.1 Introduction
Bowel obstruction is a familiar but challenging complication to surgeons. Its real
incidence is underestimated, and there is still a lot of controversy on how to avoid
it, especially among bariatric surgeons.
It is classied as early obstruction when it occurs in the 30-day postopera-
tive period.
The incidence of this complication ranges from 1 to 12% of every abdominal
surgery [1].
Regarding the etiology, the majority of the cases are due to adhesions. Other
causes are internal hernia, volvulus, intra-abdominal infection, anastomotic leak,
fascial dehiscence, and intussusception. After a laparoscopic approach, port site
hernia and internal hernia must be remembered [1].
Classically, bowel obstruction presents itself as abdominal pain, which can be
intermittent or continuous, nausea, and vomiting after eating, besides stopping
elimination of atus and feces.
Laparoscopic Roux-en-Y gastric bypass (RYGB) is the golden standard on treatment for morbid obesity [2–4]. When compared to the open technique, some of the
advantages of laparoscopic approach are less postoperative pain, decrease hospital
stay, and faster return to daily activities [3, 4].
In the specic scenery of bariatric and metabolic surgery, bowel obstruction is
also a frequent complication, with its incidence ranging from 1 to 16% in patients
undergoing RYGB [2].
A. C. Filho (*) · L. S. Jimenes · S. K. Gallani · M. A. M. P. Miranda
Hospital e Maternidade Galileo, Valinhos, SP, Brazil
Concon Clinic, Valinhos, SP, Brazil
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
A. Teixeira et al. (eds.), Duodenal Switch and Its Derivatives in Bariatric and
Metabolic Surgery, https://doi.org/10.1007/978-3-031-25828-2_49
453
454
Fig. 49.1 (1) Mesenteric
defect and (2) Petersen’s
defect [5]
Alimentery loop
2
A. C. Filho et al.
1
Biliopancreatic loop
Common channel
The main cause of bowel obstruction after RYGB is the bowel herniation through
mesenteric defect, as in Petersen’s space or in the jejunostomy defect [2–7]. The
risk of internal hernia is higher with the laparoscopic approach, ranging from 0.5 to
11% [3–7].
There are three possible anatomical sites through which intestinal loops can herniate (Figs.49.1, 49.2, and 49.3):
1. Defect in the meso-jejunostomy in the jejunum (JJ)
2. Transverse mesocolon defect in retro procedures colic (MT)
3. Petersen’s hernia (PH): defect located behind the Y-handle of Roux; between the
transverse mesocolon and the Roux loop mesentery
Petersen’s space was rst described by Md. Walther Petersen, a German surgeon,
during the 1990s. It’s the space formed between the Roux loop and the transverse
mesocolon. Petersen’s hernia is the most common hernia after RYGB, with an incidence of 0.9–5% [6] (Figs.49.4, 49.5, and 49.6).
Internal hernia can occur any time, for life long. Thus, no study was able to demonstrate its real incidence, due to insufcient follow-up [7]. However, we know that
most cases occur from 1 to 2years after surgery, coinciding with the period of greatest weight loss [4, 5].
Other causes are jejunojejunostomy-related problems (kinking of the anastomosis, hematoma and intraluminal blood clot, and adhesions [2]).
Internal hernia is the main cause of abdominal pain in the late postoperative
period [6]. It’s presentation varies from nonspecic symptoms, like intermittent
49 Internal Hernias andBowell Obstruction
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Fig. 49.2 Closure of
mesenteric defect [5]
455
1
Fig. 49.3 Closure of
Petersen’s defect [5]
1
456
Fig. 49.4 Petersen’s
defect closure [6]
Fig. 49.5 Petersen’s
defect closure [6]
A. C. Filho et al.
Fig. 49.6 Petersen’s
defect closure [6]
49 Internal Hernias andBowell Obstruction
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457
pain after eating, to dramatic clinical presentation with persistent pain and acute
obstructive abdomen [5].
Because of the nonspecic clinical presentation and the absence of reliable diagnostic imaging, it can cause a high morbidity and even mortality [3, 5].
CT scan can show swirling of the bowel mesentery vessels, dilated loops, and
clustering of those dilated loops in an atypical location. Yet, CT’s sensitivity ranges
from 28 to 89% only. Therefore, the clinical suspicion of bowel obstruction must be
enough to indicate reoperation, despite CT ndings, in order to avoid mesenteric
ischemia and bowel perforation [4].
In most cases, bowel obstruction will resolve with nonoperative treatment.
However, when it happens in patients undergoing RYGB, because of the high incidence of internal hernia, surgical approach must be necessary [1].
As they know about the possibility of unfavorable outcome associated with internal hernia, surgeons try to nd ways to avoid it. In this context, there is a great
debate on the question: whether or not to close the mesentery defects.
Several authors have shown that the closure of mesenteric defects [1–3] associated with the pre-colic position of Y on Roux reconstruction reduces the occurrence
of internal hernia [1, 3].
Those who criticize this idea argue that the closure of mesenteric defects could
lead to complications, such as anastomotic kinking, bleeding, and blood clots on
mesentery [2, 4, 6, 7]. Besides, the closure of mesenteric defects does not guarantee
that it will remain closed forever, just because new defects may arise with weight
loss [6, 7]. In practical terms, the closure of mesenteric defects is technically challenging and could be the most difcult part of the surgery, increasing the duration
of the procedure [7].
The closure of mesenteric defects, even with its comproved benet in internal
hernia prevention, still leaves some doubts. There is no determination, yet, on the
closure of the jejunojejunostomy defect, only, or associated with the closure of
Petersen’s defect too [5]. There is also no consensus on the surgical technique and
which materials to use.
When searching for data on the occurrence of internal hernia in the duodenal
switch technique, information is scarce. This is due to the fact that, despite the
improved efcacy in weight loss and remission of comorbidities, duodenal switch is
an underutilized technique, representing only 2.2% of the bariatric procedures. In
this case, internal hernia occurs in about 4–18% of patients [8].
Internal hernias are a common cause of bowel obstruction as a complication of
bariatric surgeries [9]. Probably because it is not yet a largely done procedure all
over the world, especially in countries other than the United States, the scientic
literature data concerning these events related to the duodenal switch technique is
limited.
On the other hand, internal hernias after RYGB have been a subject of great
amount of effort and concern by the bariatric surgeons in the past few years. It is
already widely known that the defect in the meso-jejunostomy, the transverse mesocolon defect in retro-colic procedures, and the Petersen’s space are the main sites
related with this type of complication (Fig.49.7).
458
A. C. Filho et al.
Retrocolic, Retrogastric
• 3 defects
• Shorter distance and less tension on
gastrojejunostomy
• Decreased leak rate
• Decreased stomal stenosis rate
• Risk of mesocolic stenosis or stricture
• 2 defects
• Longer distance and more tension on
gastrojejunostomy
• No risk of mesocolic stenosis or stricture
Antecolic, Antegastric
• Increased leak rate
• Increased stomal stenosis rate
Fig. 49.7 Advantages and disadvantages of Roux limb position [9]
Fig. 49.8 Closure of
Petersen’s defect [10]
Therefore, different methods have been extensively discussed in the aim of preventing these kinds of unfortunate outcomes. For example, the closure of mesenteric defects is defended by many, but frequently associated with prolonged operative
duration, mesenteric hematoma, and kinking of the Roux limb at level of the jejunojejunostomy [10].
In the present scenario, there is consistent evidence in favor of the closure of the
mesenteric defects .Beside that, it is notable the description of new approaches of
doing it without a high cost in short-term complications. The Endohernia® stapler
device has been showing promising results on the efcacy of the closure method,
reducing the related operative time and incidence of hematomas and problems with
the anastomosis [7, 10, 11] (Figs.49.8 and 49.9).
49 Internal Hernias andBowell Obstruction
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Fig. 49.9 Closure of
mesenteric defect [10]
Fig. 49.10 Petersen’s
defect [12]
459
FLOPPY ENTERO-ANASTOMOSIS
Nevertheless, the xation of the rst part of the jejunum to left side of the transverse mesocolon has been pointed as an interesting alternative to closing the
Petersen space, as well as contemplating the following technical points: an antecolic positioning of the jejunal loop to make the gastric reservoir anastomosis, a
linear reservoir-jejunal anastomosis with a xation suture, an orientation of the
alimentary limb so that the stump faces left and the loop descends on the right, not
dividing the omentum, performance of the procedure in the supra-mesocolic space,
and not dividing the mesentery [12, 13] (Figs. 49.10, 49.11, 49.12, 49.13,
and 49.14).
460
Fig. 49.11 Hernia orice
through Petersen’s
defect [12]
Fig. 49.12 Mesenteric
defect [12]
A. C. Filho et al.
Fig. 49.13 Hernia orice
through mesenteric
defect [12]
49 Internal Hernias andBowell Obstruction
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Fig. 49.14 Twisting of the
intestinal loop through
mesenteric defect [12]
461
49.2 Discussion
The primary closing of the mesenteric defects in bariatric surgery to prevent internal
hernia and the consequent bowel obstruction has been supported by several studies,
but the surgical technique of systematic closure is still a topic of discussion [5–
7, 14–17].
Most studies regarding the closure of mesenteric defects and its impacts were
conducted in laparoscopic RYGB, probably due to this technique being more common than duodenal switch [5–7, 14, 15]. However, there are reports of internal
hernia after duodenal switch and evidence supporting the closure of the mesenteric
defects in this technique as well [16, 17].
The closure of both Petersen’s space and the mesentery at the jejunojejunostomy
with running nonabsorbable suture reduces the incidence of internal hernias in laparoscopic Roux-en-Y gastric bypass when compared to the same technique without
closure [5–7, 14, 15]. Some studies showed an increase in internal hernias with
absorbable sutures [6] (Fig.49.15).
Due to the risk of internal hernias in the postoperative period, when performing
any abdominal surgery in patients with a history of gastric bypass or duodenal
switch, it’s recommended to review both mesenteric defects [7].
Several complications have been associated with the closure of the mesenteric
defects in laparoscopic RYGB such as incomplete closure of the mesenteric defects
causing internal hernias, kinking of jejunojejunostomy, adhesions, and consequent
small bowel obstruction and hematoma. These complications were reported at an
overall low risk of occurring [2, 18].
In regard to internal hernias, their incidence after incomplete closure was signicantly lower than after non-closure of the mesenteric defects, suggesting special
attention on performing the closure [18]. To help avoid hematoma, studies suggest
keeping the sutures supercial when closing mesenteric defects.
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