Internal hernia after gastrectomy for gastric cancer in minimally invasive surgery era

Abstract

Background The incidence and clinical presentation of internal hernia after gastrectomy have been changing in the minimally invasive surgery era. This study aimed to analyze the clinical features and risk factors for internal hernia after gastrectomy for gastric cancer. Methods We retrospectively analyzed internal hernia after gastrectomy for gastric cancer in 6474 patients between January 2003 and December 2016 at Seoul National University Bundang Hospital. Multivariable logistic regression was performed to evaluate risk factors. Results Internal hernias identified by computed tomography or surgical exploration were 111/6474 (1.7%) and the median interval time was 450 days after gastrectomy. Fourteen (0.9%) of the 1510 patients who underwent open gastrectomy and 97 (2.0%) of the 4964 patients who underwent laparoscopic gastrectomy developed internal hernia. Of the 6474 patients, internal hernia developed in 0 (0%), 9 (1.1%), 40 (3.1%), 56 (3.3%), 6 (2.3%), and 0 (0%) patients who underwent Billroth I, Billroth II, Roux-en-Y, uncut Roux-en-Y, double tract, and esophagogastrostomy reconstructions, respectively. Fifty-nine (53.2%) of 111 patients with symptomatic hernia underwent surgery. Of the 59 internal hernias, treated surgically, 32 (53.2%), 27 (45.8%), and 0 (0%) were identified in jejunojejunostomy mesenteric, Petersen’s, and transverse colon mesenteric defects, respectively. In multivariate analysis, non-closure of mesenteric defects ( P < 0.01), laparoscopic approach ( P < 0.01), and totally laparoscopic approach ( P = 0.03) were independent risk factors for internal hernia. Conclusions The potential spaces such as Petersen’s, jejunojejunostomy mesenteric, and transverse colon mesenteric defects should be closed to prevent internal hernia after gastrectomy for gastric cancer.

Closure of Petersen's defect in gastrectomy for gastric cancer: an interrupted time-series analysis from a high-volume institution in China

“…The analysis of the risk factors for IH and SIH additionally validated these ndings. Our results were consistent with those of previous studies 9, 20,24 .…”

“…The overall rate of IH was 0.8% in our study, and it ranged from 0.19-5% in previous studies 1,7,8,20 . The rate of IH varied greatly among different literatures.…”

“…2). The "whirl sign" on CT examination was con rmed by two radiologists and was described in previous studies 11,12,[18][19][20] . SBO was de ned as an episode of intestinal obstruction found during surgery that was caused by IH or adhesions, or no other causes of mechanical intestinal obstruction (obstructive tumor, incisional hernia, inguinal hernia, intussusception, etc.)…”

Fixation of Roux Limb and Duodenal Stump Effects the Prevention of Peterson’s Internal Hernia and Roux Stasis Syndrome After Laparoscopic Distal Gastrectomy

“…There are reports that a laparoscopic approach, non-closure of mesenteric defects, and low BMI are independent risk factors for internal hernia by multivariate analysis [5.13.14.15]. One study reported a higher incidence of internal hernia after single-port surgery compared to multi-port surgery, resulting from the relatively difficult manipulation of laparoscopic instruments in single-port surgery [15].…”

An easy and reliable method to close Petersen's defect using barbed suture to prevent internal hernia from developing after gastrectomy with Roux‐en‐Y reconstruction

“…Internal hernia occurs in 2% to 5% of patients who undergo gastrectomy with Roux-en-Y reconstruction, leading to the development of critical morbidity. [1][2][3][4][5] Internal hernia developing after gastrectomy with Roux-en-Y reconstruction through the antecolic route occurs by intestinal invagination into two defects: the jejuno-jejunal mesenteric defect, which is formed by the jejunal mesenteries of the Roux limb and afferent limb after jejuno-jejunal anastomosis, and Petersen's defect, which is formed by the jejunal mesentery of the Roux limb and the transverse colic mesentery. 6 Previous studies recommended closure of both the jejuno-jejunal mesenteric defect and Petersen's defect to prevent internal hernia after gastrectomy with Roux-en-Y reconstruction.…”