Multiple Internal Hernias: A Complication of Laparoscopic Roux-en-Y Gastric Bypass

Abstract

Introduction: Internal hernias are the most common cause of small bowel obstruction following laparoscopic Roux-en-Y gastric bypass surgery (LRYGBP) with four distinct types. Herein, we report the clinical course of a patient with two independent hernias at the Petersen's space and a rarer subtype at the jejunojejunal window. A high index of suspicion for less common subtypes of internal hernias and the possibility of multiple, simultaneous internal hernias is critical.

Case description: We describe the case of a 52-year-old female with a history of LRYGBP who presented with abdominal pain and emesis due to an internal hernia at Peterson's defect, requiring subsequent laparoscopic repair. On postoperative day three, the patient presented again with recurrent abdominal pain and emesis. Repeat exploratory laparoscopy found a separate internal hernia involving the jejunojejunal window with the previously repaired Petersen's defect intact.

Discussion: This case illustrates a unique scenario of a patient post-LRYGBP with multiple internal hernias at the Peterson's space and the less common jejunojejunal window, which was missed during the index surgery. Failure to identify simultaneous hernias may result in additional invasive intervention and further morbidity.

Conclusion: Multiple less-common variants of internal hernias may present simultaneously following LRYGBP.

Keywords: Gastric Bypass; Hernia; Laparoscopic surgery; Roux-en-Y; Surgical complications.

Figure 1.

Noncontrast computed tomography obtained for evaluation of internal hernia six months following laparoscopic Roux-en-Y gastric bypass operation showing dilated bowel proximal to the jejunojejunal anastomosis with distal decompression (arrow), but without reported evidence of mesenteric swirling.

Figure 2.

Three days after initial internal hernia repair at petersen’s space, repeat noncontrast computed tomography revealed proximal jejunal dilation with a transition point at the jejunojejunal anastomosis (arrow) and concern for mesenteric swirling suggestive of internal herniation at the jejunojejunal window.