title: Internal hernia after laparoscopic Roux-en-Y gastric bypass.
abstract: BACKGROUND
  Internal hernia (IH) is a technical complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP) that can have severe consequences. Little has been written on characterizing this complication. Antecolic Roux limb passage has been suggested to be safe without defect closure.
  
  
  METHODS
  The records of 785 patients who underwent LRYGBP (136 antecolic, 649 retrocolic) between 1998 and 2003 were reviewed. In our early experience (n = 107), we used a retrocolic technique without defect closure.
  
  
  RESULTS
  Twenty patients underwent surgical intervention for IH. The median interval between LRYGBP and symptom onset was 303 days (range, 25 to 1642 days). Abdominal pain was uniformly present, and 63% of patients developed nausea and/or vomiting. Exploratory laparoscopy was attempted in 94% of patients; conversion was necessary in 33%. A total of 21 IHs were identified (13 Petersen's, 5 mesocolic, 2 jejunojejunal, and 1 adhesion-related hernia). No nonviable bowel was identified, and no deaths occurred. A retrocolic technique involving closure of all defects resulted in the lowest rate of hernias (3/542; 0.55%) compared with the antecolic (12/136; 8.81%; P < .0001) and early retrocolic techniques (6/107; 5.6%; P < .0002).
  
  
  CONCLUSIONS
  IH can occur long after gastric bypass surgery, and a low threshold for reoperation is crucial to avoid gut infarction. A retrocolic technique with defect closure appears to afford the lowest risk of IH. The lower incidence of IH in other series after antecolic technique likely results from a less aggressive detection and management approach, because our nonclosure technique could not differ from that of other authors. All defects must be closed to minimize the risk of hernia, whether antecolic or retrocolic.
authors.affiliation: Division of General Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia, USA.
authors.forename: Brennan
authors.initials: B
authors.lastname: Carmody
authors.forename: Eric J
authors.initials: EJ
authors.lastname: DeMaria
authors.forename: Mohammad
authors.initials: M
authors.lastname: Jamal
authors.forename: Jason
authors.initials: J
authors.lastname: Johnson
authors.forename: Alfredo
authors.initials: A
authors.lastname: Carbonell
authors.forename: John
authors.initials: J
authors.lastname: Kellum
authors.forename: James
authors.initials: J
authors.lastname: Maher
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects; D005260:Female; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods; D046449:Hernia, Abdominal / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies