title: Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass.
abstract: BACKGROUND
  Mesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population.
  
  
  METHODS
  The records of 702 consecutive patients undergoing primary laparoscopic Roux-en-Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO. During the last 9 months of the study, we offered elective laparoscopy to any patient who presented to us with symptoms of intermittent SBO.
  
  
  RESULTS
  Of the 702 patients, 27 (3.8%) developed acute SBO. Of these 27 patients, 15 (55%) had obstruction related to an MIH. Nearly all patients had a typical history of intermittent abdominal pain, nausea, and bloating before developing acute SBO. Elective laparoscopy was offered to 11 patients with symptoms of intermittent SBO. Two patients who refused subsequently underwent operations for acute SBO. MIH was found at elective laparoscopic exploration in all cases. Of the 9 patients undergoing elective surgery, 3 (33%) had small bowel volvulus.
  
  
  CONCLUSIONS
  SBO due to MIH after laparoscopic Roux-en-Y gastric bypass is typically preceded by symptoms of intermittent obstruction. Patients who have these herald symptoms should promptly be offered elective laparoscopic exploration. Elective repair of MIH can be performed safely and expeditiously.
authors.affiliation: Bariatric Surgery, University Medical Center at Princeton, Princeton, New Jersey, USA. dr.agandhi@gmail.com
authors.forename: Alok D
authors.initials: AD
authors.lastname: Gandhi
authors.forename: Rohit A
authors.initials: RA
authors.lastname: Patel
authors.forename: Robert E
authors.initials: RE
authors.lastname: Brolin
mesh_terms: D000208:Acute Disease; D017558:Elective Surgical Procedures / Q000379:methods; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods; D006547:Hernia / Q000150:complications; D059685:Herniorrhaphy; D006801:Humans; D007415:Intestinal Obstruction / Q000209:etiology* / Q000601:surgery; D007579:Jejunal Diseases / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery; D007582:Jejunostomy / Q000379:methods; D010535:Laparoscopy / Q000379:methods*; D008643:Mesentery; D009767:Obesity, Morbid / Q000601:surgery*; D011183:Postoperative Complications; D012086:Reoperation; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome