Internal Herniation After Laparoscopic Roux-en-Y Gastric Bypass Surgery: Pitfalls in Diagnosing and the Introduction of the AMSTERDAM Classification

Abstract

The large variation in reported IH incidence is due to the large variation in IH definition. To gain more uniformity in reporting IH prevalence, we propose the use of the AMSTERDAM classification. Post-LRYGB patients with acute onset crampy/colicky epigastric pain should undergo abdominal ultrasound to rule out gallbladder pathology and offered re-laparoscopy with a low threshold. IH incidence is highest among patients with rapid weight loss and non-closure of intermesenteric defects.

Predictive value of abdominal CT in evaluating internal herniation after bariatric laparoscopic Roux-en-Y gastric bypass

“…The median interval from initial surgery to the start of complaints indicative of internal herniation was 14 (range 0-54) months. This is comparable to recent studies that reported a median time until internal herniation diagnosis of 9 and 15 months respectively 3,5 . The most frequent complaint was abdominal pain, which occurred in 98⋅5 per cent of the episodes.…”

“…A Petersen herniation was seen in half of those with an internal herniation in this study (22 of 42). In older studies 6,10,13,14 , jejunojejunostomy hernias occurred more frequently than Petersen hernias, whereas more recent studies 3,5,9,11 found more Petersen hernias, with rates ranging from 40⋅5 to 75 per cent. Defects were found to be equally distributed over the two sites in the present study.…”

“…Abdominal cramping or colic pain in the umbilical region was significantly more common in the internal herniation group. Geubbels and colleagues reported that cramping or colic pain was the most common symptom in patients with internal herniation. Abdominal pain, nausea or vomiting were the most common complaints in several previous studies.…”

“…Another limitation might be the follow‐up time of 2–5 years, as the time until presentation with complaints varies from less than 24 h after surgery to 9 years. Although 90 per cent of internal herniations develop within 20–36 months, longer follow‐up might have resulted in a higher incidence.…”

“…Clinical symptoms are not specific for internal herniation and vary in severity, ranging from intermittent symptoms in the event of transient herniation of the bowel through a mesenteric defect, to severe and acute complaints after small bowel obstruction or strangulation of the vessels. Because of the risk of strangulation, internal herniation is a potentially life‐threatening condition that requires surgical treatment.…”