title: Favorable internal hernia rate achieved using retrocolic, retrogastric alimentary limb in laparoscopic Roux-en-Y gastric bypass.
abstract: BACKGROUND
  The present study was performed at a tertiary care university hospital. The present study examined the incidence of internal hernia (IH) in our series of laparoscopic Roux-en-Y gastric bypass (LRYGB) with retrocolic, retrogastric routing of the alimentary limb accompanied by routine secure closure of all mesenteric defects.
  
  
  METHODS
  During a 4-year period, 847 patients underwent LRYGB. Our operative technique included retrocolic, retrogastric placement of the alimentary limb. The enteroenterostomy mesenteric defect, mesocolic defect, and Petersen defect were routinely closed in running fashion with nonabsorbable suture.
  
  
  RESULTS
  The study population had a mean age of 42.4 +/- 9.3 years and a mean preoperative body mass index of 45.3 +/- 5.6 kg/m(2). The mean operative time was 154 +/- 25 minutes. The mean excess body weight loss at 1 year was 70%. The incidence of IH among this large study population was 0%. A total of 11 patients (1.3%) presented with symptoms concerning for IH, most commonly nausea, vomiting, and crampy abdominal pain, from 1 month to 6 years after the initial surgery. On re-exploration, 4 patients had adhesive small bowel obstruction, 4 had adhesions without obstruction, 1 had small bowel intussusception, and 2 patients had negative findings.
  
  
  CONCLUSIONS
  IH is a serious complication of LRYGB that can lead to catastrophic morbidity and mortality. We advocate vigilant screening for this complication and laparoscopic exploration for patients with worrisome symptoms. Our data have indicated that a routine and consistent technique to securely close the mesenteric defects can significantly reduce the risk of IH associated with retrocolic, retrogastric placement of the alimentary limb during LRYGB.
authors.affiliation: Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA 95817, USA.
authors.forename: Linda A
authors.initials: LA
authors.lastname: Miyashiro
authors.forename: William D
authors.initials: WD
authors.lastname: Fuller
authors.forename: Mohamed R
authors.initials: MR
authors.lastname: Ali
mesh_terms: D000328:Adult; D000714:Anastomosis, Surgical; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods; D046449:Hernia, Abdominal / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D007421:Intestine, Small / Q000601:surgery*; D010535:Laparoscopy; D008875:Middle Aged; D009767:Obesity, Morbid / Q000601:surgery*; D012189:Retrospective Studies