title: Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery.
abstract: BACKGROUND
  Roux-en-Y gastric bypass (RYGBP) has long been associated with the possible development of internal hernias, with a reported incidence of 1-5%. Because it induces fewer adhesions than laparotomy, the laparoscopic approach to this operation appears to increase the rate of this complication, which can present dramatically.
  
  
  METHODS
  Data from all patients undergoing bariatric surgery are introduced prospectively in a data-base. Patients who were reoperated for symptoms or signs suggestive of an internal hernia were reviewed retrospectively, with special emphasis on clinical and radiological findings, and surgical management.
  
  
  RESULTS
  Of 607 patients who underwent laparoscopic primary or reoperative RYGBP in our two hospitals between June 1999 and January 2006, 25 developed symptoms suggestive of an internal hernia, 2 in the immediate postoperative period, and 23 later on, after a mean of 29 months and a mean loss of 14.5 BMI units. 9 of the latter presented with an acute bowel obstruction, of which 1 required small bowel resection for necrosis. Recurrent colicky abdominal pain was the leading symptom in the others. Reoperation confirmed the diagnosis of internal hernia in all but 1 patient. The most common location was the meso-jejunal mesenteric window (16 patients, 56%), followed by Petersen's window (8 patients, 27%), and the mesocolic window (5 patients, 17%). Patients in whom the mesenteric windows had been closed using running non-absorbable sutures had fewer hernias than patients treated with absorbable sutures at the primary procedure (1.3% versus 5.6%, P=0.03). Except in the acute setting, clinical and radiological findings were of little help in the diagnosis.
  
  
  CONCLUSIONS
  Except in the setting of acute obstruction, clinical and radiological findings usually do not help in the diagnosis of internal hernia. A high index of suspicion, based mainly on the clinical history of recurrent colicky abdominal pain, is the only means to reduce the number of acute complications leading to bowel resection by offering the patient an elective laparoscopic exploration with repair of all the defects. Prevention by carefully closing all potential mesenteric defects with running non-absorbable sutures during laparoscopic RYGBP, which we consider mandatory, seems appropriate in reducing the incidence of this complication.
authors.affiliation: Department of Visceral Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland.
authors.forename: A
authors.initials: A
authors.lastname: Paroz
authors.forename: J M
authors.initials: JM
authors.lastname: Calmes
authors.forename: V
authors.initials: V
authors.lastname: Giusti
authors.forename: M
authors.initials: M
authors.lastname: Suter
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects*; D006547:Hernia / Q000209:etiology*; D006801:Humans; D007410:Intestinal Diseases / Q000175:diagnosis / Q000209:etiology* / Q000517:prevention & control; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D012189:Retrospective Studies; D013997:Time Factors