Does the non-absorbable suture closure of the jejunal mesenteric defect reduce the incidence and severity of internal hernias after laparoscopic Roux-en-Y gastric bypass?

Abstract

Purpose Internal hernias (IH) are frequent complications after laparoscopic Roux-en-Y gastric bypass (LRYGB). Closure of the jejunal mesenteric and the Petersen defect reduces IH incidence in prospective and retrospective trials. This study investigates whether closing the jejunal mesenteric space alone by non-absorbable suture and splitting the omentum can be beneficial to prevent IH after LRYGB. Methods Observational cohort study of 785 patients undergoing linear LRYGB including omental split at a single institution, with 493 patients without jejunal mesenteric defect closure and 292 patients with closure by non-absorbable suture, and a minimal follow-up of 2 years. Patients were assessed for appearance and severity of IH. Additionally, open mesenteric gaps without herniated bowel as well as early obstructions due to kinking of the entero-enterostomy (EE) were explored. Results Through primary mesenteric defect closure, the rate of manifest jejunal mesenteric and Petersen IH could be reduced from 6.5 to 3.8%, but without reaching statistical significance. The most common location for an IH was the jejunal mesenteric space, where defect closure during primary surgery reduced the rate of IH from 5.3 to 2.4%. Higher weight loss seemed to increase the risk of developing an IH. Conclusion The closure of the jejunal mesenteric defect by non-absorbable suture may reduce the rate of IH at the jejunal mesenteric space after LRYGB. However, the beneficial effect in our collective is smaller than expected, particularly in patients with good weight loss. The Petersen IH rate remained low by consequent T-shape split of the omentum without suturing of the defect.

Meticulous Closure of Mesenteric Defects Effectively Reduces the Incidence of Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass

“…In the present series, TWL was higher in patients who developed IH. Schneider et al also reported lower BMIs in patients with IH than in the rest of their cohort [33]. With more weight loss, the mesenteries become thinner, which probably facilitates herniation through a small defect.…”

Hérnias internas após bypass gástrico laparoscópico em Y-de-Roux: espaços intermesentéricos, sintomas e diagnóstico

“…Devido ao crescente número de pacientes submetidos a ele, os cirurgiões se deparam com altos números de complicações pós-operatórias, dentre elas, o desenvolvimento de HIs. 2,5,7 Este bypass envolve a criação de pequena bolsa gástrica seguida pela divisão do jejuno proximal a 25-50 cm do ângulo duodenojejunal. O jejuno dividido resulta em 2 alças separadas: uma alimentar, também conhecida como membro de Roux, e outra biliopancreática.…”

“…Ainda assim, a literatura indica o fechamento dos defeitos mesentéricos criados, com suturas contínuas não absorvíveis ou com grampos não absorvíveis. 2,4,[7][8][9][10]12 O conhecimento das várias configurações de bypass gástrico (antecólica, retrocólica, bypass gástrico de 1 anastomose), o espectro de aparências de imagem é crucial para esclarecer os defeitos anatômicos específicos observados em estudos de imagem. Efetivamente, sempre haverá dificuldade na interpretação e avaliação das imagens de tomográficas de pacientes pós-bypass gástrico.…”

“…Outros fatores que estão relacionados ao surgimento da HI são a perda de peso, o afinamento dos mesos do intestino delgado e do cólon, e a falta de fechamento dos defeitos criados. 4,7,10,11 As HI podem aparecer em qualquer momento do pós-operatório, mas são mais frequentes entre o 1º. e 2º.…”

Risk Factor and Surgical Outcome of Petersen’s Hernia After Gastrectomy in Gastric Cancer

“…The incidence of Petersen’s hernia is quite low, ranging between 1% and 5% ( 4 , 5 ). Such low incidence makes it impossible to conduct prospective studies.…”