Incarceration of the Afferent Loop into the Sutured Closed Mesenteric Defect after Gastrectomy Followed by Billroth-II Reconstruction for Gastric Cancer: Two Case Reports

Abstract

Introduction: Internal hernia is a critical complication after laparoscopic gastrectomy with Roux-en-Y, Billroth-II or double tract reconstruction. It is recommended that mesenteric defects should be closed to prevent internal hernias. We reported two patients who developed internal hernias, in which the afferent loop of Billroth-II reconstruction became incarcerated into the closed mesenteric defects.

Case presentation: A man in his late 40s had undergone laparoscopic distal gastrectomy 3 months prior for gastric cancer followed by Billroth-II reconstruction, in which mesenteric defect was sutured closed. The patient visited our hospital complaining of sudden severe upper abdominal pain and was diagnosed with afferent loop obstruction due to an incarcerated internal hernia complicated by acute pancreatitis. Emergency surgery, in which intestinal incarceration was relieved and intestinal ischemia was not found, was performed on the same day as admission. However, postoperative duodenal microperforation occurred, making treatment difficult. A woman in her late 70s had undergone laparoscopic distal gastrectomy 7 days prior for gastric cancer followed by Billroth-II reconstruction, in which mesenteric defect was sutured closed. The patient complained of nausea without abdominal pain and was diagnosed with afferent loop obstruction due to an incarcerated internal hernia. Emergency surgery, in which intestinal incarceration was relieved and intestinal ischemia was not found, was performed on the same day. The patient was discharged uneventfully. In both cases, a hernia orifice formed in the Treiz ligament area, and the afferent loop was incarcerated into the closed mesenteric defect.

Conclusions: Incarcerated internal hernias should be treated as soon as possible. Although closure of the mesenteric defects after Billroth-II reconstruction is necessary to prevent internal hernias, mesenteric defects should be closed on the left side as far away from the Treiz ligament as possible.

Keywords: Billroth-II reconstruction; gastric cancer; internal hernia; laparoscopic surgery; mesenteric defect.

Fig. 1. CT scan revealed abnormal dilation of the intestine from the duodenum to the afferent loop (white arrow) and widespread edema in the right retroperitoneum posterior to the duodenum (yellow arrow).

Fig. 2. The incarcerated afferent loop (white allow) was carefully and gently returned to its original position. It was found after hernia reduction that a hernia orifice (yellow arrow) formed between the lower end of the suture line (red arrow) in the initial operation and the Treiz ligament.

Fig. 3. CT scan revealed abnormal dilation of the intestine from the duodenum to the afferent loop (white arrow) and stricture after the dilatation (yellow arrow).

Fig. 4. The incarcerated afferent loop (white allow) was carefully and gently returned to its original position. It was revealed after hernia reduction that a hernia orifice (yellow arrow) formed between the lower end of the suture line (red arrow) in the initial operation and the Treiz ligament.

Fig. 5. This schema shows the mechanism of IH after Billroth II. As a result of closure of the MD adjacent to the Treiz ligament, a hernia orifice was formed at the site. The duodenum at the Treiz ligament was pulled dorsally and the afferent loop was retracted into the hernia orifice.

Fig. 6. Surgical findings in the initial operation in case 1. Afferent loop (white arrow). The mesenteric defect was continuously closed using a nonabsorbable barbed suture, with the starting point (yellow arrow) close to the Treiz ligament and the proceeding suture toward the gastric remnant (red arrow). This method involved shortening the suture line (red arrow) and lifting upward the sutured mesenterium (blue arrow), resulting in the formation of a hernia orifice (triangle) close to the Treiz ligament.

Fig. 7. To prevent the development of the IH, the MD should be closed with the starting point of the suture and the suture line being at the left side as far as possible from the Treiz ligament.