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INTRODUCTION: Although laparoscopic Roux-en-Y gastric bypass (LRYGB) has decreased morbidity compared to the open approach, it was initially associated with a higher rate of internal hernia (IH). This study investigated the impact of mesenteric defect closure on the rate and characteristics of IH after LRYGB.
METHODS: Retrospective review was conducted on all patients undergoing LRYGB from 2001-2011. Only patients who had all defects closed (DC) or all defects not closed (DnC) were included. Patients with an incidentally identified IH during another operation were excluded. Data collected included demographics, clinical presentation, operative details, and postoperative course. Data were analyzed using SPSS (version 16) statistical software.
RESULTS: Of 1160 patients who underwent LRYGB from 2001-2011, 914 met inclusion criteria [DC=663 (72.5%) patients and DnC=251 (27.5%)]. Median follow-up was 24.3 (range 0.5-93.3) vs 31.7 months (range 0.5-131) in DC vs DnC, respectively (p<0.0001). A total of 46 patients (5%) developed a symptomatic IH [25 (3.8%) in DC vs 21 (8.4%) in DnC group, p=0.005]. This remained statistically significant on multivariate analysis (p=0.0098, OR 0.44; 95% CI 0.24-0.82). Nineteen patients (42.2%) presented for emergent or urgent repair and 26 (57.8%) for elective repair. The most common symptom was chronic post-prandial abdominal pain (53.4%), followed by abdominal pain with nausea ± vomiting (35.6%), acute abdominal pain ± nausea and vomiting (8.8%), and an acute abdomen (2.2%). Median time to presentation from LRYGB was 16.6 (range 3.1-71.9) vs 33.5 months (range 10-103) in the DC vs DnC group, respectively (p<0.001). At the time of IH repair there was no significant difference in BMI or %EWL between the two groups. All patients underwent CT scan which was consistent with IH in 26 patients (57.5%), suggestive in 7 (15.6%), showed small bowel obstruction in 4 (8.9%), and was negative in 8 (17.8%). The majority of IH repairs were performed laparoscopically (86.7%) vs open (13.3%). Intra-operatively, 71 herniation sites were identified. In the DC group, there were 23 (67.6%) pseudo-Peterson's and 11 (32.4%) meso-mesoenteric defects. In the DnC group, there were 5 (13.5%) mesocolic, 15 (40.5%) Peterson's, 2 (5.4%) pseudo-Peterson's, and 15 (40.5%) meso-mesenteric defects. Median OR time was 104 minutes (range 75-180). Median length of stay was 1 day (range 0.5-32). One patient who presented in extremis died after being hospitalized elsewhere for 3 days with the incorrect diagnosis. One patient had IH recurrence 11.5 and 14.2 months after initial repair.
CONCLUSIONS: Complications of IH can be devastating and closure of mesenteric defects during LRYGB significantly lowers IH rate. A high index of suspicion must be maintained since symptoms may be nonspecific and imaging may be negative in nearly 20% of patients.