Petersen's hernia after living donor liver transplantation

Abstract

Background: Hepaticojejunostomy may be used for biliary reconstruction in certain cases of liver transplantation. In this occasion, Roux-en-Y biliary reconstruction is predominantly performed. Petersen's hernia is an internal hernia that can occur after Roux-en-Y reconstruction, and it may lead to extensive ischemic changes affecting incarcerated portions of the small bowel or Roux limb resulting in severe complications with a poor prognosis.

Case presentation: The present case was a 44-year-old male who underwent living donor liver transplantation (LDLT) for familial amyloid polyneuropathy and in whom biliary reconstruction was performed with Roux-en-Y hepaticojejunostomy. Two years after liver transplantation, symptomatic bowel strangulation was diagnosed by CT examination and emergent surgery was performed accordingly. On exploration, an ischemic limb associated with Petersen's hernia was observed. Although repositioning of the incarcerated bowel loop gradually improved the color of the limb, the limb failed to completely recover to a normal color. To allow accurate evaluation for the viability of the limb, we decided to perform a second-look operation after 48 h. On re-exploration, the surface of the limb remained a dark color; however, intraoperative endoscopic findings revealed only partial necrosis of the mucosa. Next, we resected the portion of ischemic damaged limb only following side-to-side jejunojejunostomy. Consequently, redoing of biliary reconstruction could be avoided and the original hepaticojejunostomy site was preserved. Although the stricture of the remnant Roux limb occurred 1 month thereafter, it was successfully managed by balloon dilation via percutaneous transhepatic biliary drainage route.

Conclusions: The occurrence of Petersen's hernia should always be considered in cases of liver transplantation with Roux-en-Y biliary reconstruction. On the basis of an accurate assessment of the extent of jejunal limb injury, reanastomosis of the hepaticojejunostomy, a potentially high-risk surgical procedure, can be avoided in emergent situations.

Keywords: Biliary reconstruction; Hepaticojejunostomy; Living donor liver transplantation; Petersen’s hernia.

Fig. 1

Enhanced abdominal CT scan on an arrival a Coronal plane. b, c Transverse plane. a–c CT demonstrated dilated, fluid-filled small bowel loops with poor enhancement of the bowel wall. Arrows indicate a markedly dilated Roux limb. c. The triangle arrow indicates a “whirl” appearance

Fig. 2

Operative findings. We identified an internal hernia through Petersen’s defect between the limb and mesocolon (triangle arrow). The incarcerated small bowel loop resulted in ischemia of the Roux limb (arrow)

Fig. 3

Intraoperative endoscopy view during re-exploration. Intraoperative endoscopic findings revealed only partial ischemic injury to the mucosa only

Fig. 4

Stenosis of Roux limb at a month after discharge and the treatments. a CT showed dilatation of both the limb and intrahepatic bile ducts. Arrow indicates stenosis of the limb. b Tube cholangiogram through a PTBD tube of 12 Fr inserted across the stenotic lesion of Roux limb. Arrows indicate stenosis of the limb. The triangle arrow indicates the intact hepaticojejunostomy anastomosis. c Balloon dilation of the stenotic portion of the limb (12 mm in diameter). d The PTBD tube was removed 2 years after the emergency event. Arrows indicate the expanded limb