title: Laparoscopic antecolic Roux-en-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach.
abstract: BACKGROUND
  Laparoscopic Roux-en-Y gastric bypass surgery reportedly has a higher rate of postoperative internal hernias than open bypass surgery. Even with closure of mesenteric defects, hernias occur in up to 9% of cases. To minimize this complication, an antecolic antegastric approach to anastomosis of the Roux limb and gastric pouch has been used. Whereas the retrocolic retrogastric technique creates three mesenteric defects, the antecolic approach produces only two: Petersen's defect and the jejunojejunostomy. The rate of internal hernias was compared among patients undergoing laparoscopic Roux-en-Y gastric bypass surgery using the retrocolic and antecolic approaches.
  
  
  METHODS
  The experience of a single surgeon from August 2001 to September 2005 was reviewed. Only Roux-en-Y gastric bypass procedures were included. Patients were followed for a minimum of 18 months postoperatively. The retrocolic approach was used for 274 patients and the antecolic approach for 205 patients. All defects were closed at the time of surgery. With the antecolic approach, Petersen's defect was closed from the root of the mesentery of the Roux limb and the transverse colon mesentery up to the transverse colon.
  
  
  RESULTS
  Of the 274 patients, 7 (2.6%) experienced a symptomatic internal hernia with the retrocolic retrogastric technique. No internal hernias were reported among the 205 patients treated with the antecolic antegastric method. Chi-square analysis showed that an antecolic approach was associated with a decreased rate of internal hernias (p < 0.025). Of 479 patients, 35 (7%) underwent diagnostic laparoscopy without any internal hernia found. Of these patients, 15 were found to have cholelithiasis and subjected to laparoscopic cholecystectomy.
  
  
  CONCLUSIONS
  The antecolic antegastric approach to laparoscopic Roux-en-Y gastric bypass is associated with fewer postoperative hernias than the retrocolic retrogastric approach. The frequency of hernias using either technique is low if meticulous attention is paid to closure of all mesenteric defects.
authors.affiliation: Department of Surgery A5, Johns Hopkins Bayview Medical Center, Baltimore, MD 21224, USA. ksteele3@jhmi.edu
authors.forename: K E
authors.initials: KE
authors.lastname: Steele
authors.forename: G P
authors.initials: GP
authors.lastname: Prokopowicz
authors.forename: T
authors.initials: T
authors.lastname: Magnuson
authors.forename: A
authors.initials: A
authors.lastname: Lidor
authors.forename: M
authors.initials: M
authors.lastname: Schweitzer
mesh_terms: D017081:Cholecystectomy, Laparoscopic / Q000379:methods; D002769:Cholelithiasis / Q000150:complications / Q000601:surgery; D015390:Gastric Bypass / Q000379:methods*; D006555:Hernia, Ventral / Q000209:etiology / Q000517:prevention & control*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control*; D012189:Retrospective Studies