Gender, racial, and socioeconomic disparity of preoperative optimization goals in ventral hernia repair.

BACKGROUND: Preoperative optimization cut-offs are frequently utilized to determine eligibility for elective ventral hernia repair. Our objective was to assess the relationship between gender, race, and socioeconomic status and preoperative optimization goals. METHODS: We queried our institutional database for adults with ventral hernia diagnoses between 2016 and 2021. Demographics, comorbidities, laboratory, and operative data were collected and analyzed. The following cut-offs were used to determine eligibility for elective repair: body mass index (BMI) < 40 kg/m2, no active smoking, and glycated hemoglobin (HbA1c) < 8%. Socioeconomic status was assessed using the Distressed Communities Index. RESULTS: A total of 5638 patients were included [Whites = 4321 (77%), Blacks = 794 (14%), Hispanics = 318 (6%), and other/unknown 205 (4%)]. Median age was 61 years and 50% were male. Most common hernia types were umbilical (36%) and incisional (20%). 10% had BMI > 40 kg/m2, 9% were active smokers and 4% had HbA1c > 8%. 21% of all patients did not meet the preoperative optimization cut-offs at time of diagnosis and those were less likely to undergo hernia repair during the study timeframe compared to those who did (OR 0.50; 95% CI [0.42-0.60]). There was a higher proportion of females (21%) and Blacks (22%) with BMI > 40 kg/m2 compared to males (11%) and other races (11-15%), p = 0.002. As the level of socioeconomic distress increased, there was a corresponding increase in the proportion of patients who did not meet preoperative optimization cut-offs from 16% in prosperous communities to 25% in distressed communities (p < 0.0001). CONCLUSION: Nearly 1 of 5 patients with ventral hernias is affected by commonly used arbitrary preoperative optimization cut-offs. These cut-offs disproportionately impact females, Black patients and those with higher socioeconomic distress. These disparities need to be considered when planning preoperative optimization protocols and resource allocation to ensure equitable access to elective ventral hernia repair.

S041-Trends and short-term outcomes of three approaches to minimally invasive repair of small ventral hernias. An ACHQC analysis.

INTRODUCTION: Different approaches and mesh positions are used for minimally invasive ventral hernia repair (MIS-VHR). Our aim was to evaluate the trends and short-term outcomes of intraperitoneal onlay mesh (IPOM), preperitoneal, and retromuscular repairs for small ventral hernias. METHODS: We conducted a retrospective cohort study using the Abdominal Core Health Quality Collaborative (ACHQC). We included elective MIS-VHR in adults with hernia defect width < = 6 cm from 2012 to 2021. We compared patient/hernia characteristics, trends, and short-term outcomes between IPOM, preperitoneal, and retromuscular repairs. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. RESULTS: A total of 7261 patients were included (IPOM = 4484, preperitoneal = 1829, retromuscular = 948). Preperitoneal repair was associated with lower rates of incisional (preperitoneal = 37%, IPOM = 63%, retromuscular = 73%) and recurrent hernias (preperitoneal = 11%, IPOM = 21%, retromuscular = 22%) compared to IPOM and retromuscular. Median defect width was 3.0, 2.0, and 4.0 cm for IPOM, preperitoneal, and retromuscular, respectively. There has been a progressive increase in the proportion of preperitoneal and retromuscular repairs over time (10% in 2013-53% in 2021 of all MIS-VHR). Robotic approach was more frequently utilized in preperitoneal and retromuscular (both > 85%) compared to IPOM (47%). Transversus abdominis release was performed in 14% of retromuscular repairs. After IPTW, no clinically significant differences were noted in the short-term outcomes between IPOM versus preperitoneal. Retromuscular repairs were associated with higher risk of 30-day reoperation (OR = 3.54, 95%CI [1.67, 7.5] and OR = 5.29, 95%CI [1.23, 22.74]) compared to IPOM and preperitoneal repairs, respectively, and higher risk of 30-day readmission compared to preperitoneal repairs (OR = 2.6, 95%CI [2.6, 6.4]). CONCLUSION: Based on ACHQC data, preperitoneal and retromuscular approaches for MIS-VHR of small hernias have increased over time and are primarily performed robotically. Transversus abdominis release was performed in 14% of retromuscular repairs of these small hernias. Retromuscular repairs were associated with higher 30-day readmission and reoperation rates compared to the other approaches.

S-144 lack of association between glycated hemoglobin and adverse outcomes in diabetic patients undergoing ventral hernia repair: an ACHQC study.

INTRODUCTION: Elevated preoperative glycated hemoglobin (HbA1c) is believed to predict complications in diabetic patients undergoing ventral hernia repair (VHR). Our objective was to assess the association between HbA1c and outcomes of VHR in diabetic patients. METHODS: We conducted a retrospective cohort study using the Abdominal Core Health Quality Collaborative (ACHQC) database. We included adult diabetic patients who underwent elective VHR with an available HbA1c result. The patients were divided into two groups (HbA1c < 8% and HbA1c ≥ 8%). Patient demographics, comorbidities, hernia characteristics, operative details, and surgical outcomes were compared. Multivariable logistic regression analysis of complications was performed. Cox proportional hazard regression was used to assess probability of composite recurrence at different HbA1c levels. RESULTS: 2167 patients met the inclusion criteria (HbA1c < 8% = 1,776 and HbA1c ≥ 8% = 391). Median age was 61 years and median body mass index was 34 kg/m2. 75% had an American Society of Anesthesiology class of 3. The median HbA1c was 6.5% in the HbA1c < 8% group versus 8.7% in the HbA1c ≥ 8% group. 73% were incisional hernias, 34% were recurrent, and median hernia width was 6 cm. Open approach was used in 63% and myofascial release was performed in 46%. Median follow-up was 27 days. There were no clinically significant differences in the rates of overall 30-day complications, wound complications, reoperation, readmission, mortality, length of stay and quality of life and pain scores between the two groups. Regression analyses did not identify an association between HbA1c and the rates of complications, surgical site infection or composite recurrence across the spectrum of HbA1c values. CONCLUSION: Our study finds no evidence of an association between HbA1c and operative outcomes in diabetic patients undergoing elective VHR.

The effect of smoking status on inguinal hernia repair outcomes: An ACHQC analysis.

BACKGROUND: Smoking has been shown to negatively affect surgical outcomes, so smoking cessation prior to elective operations is often recommended. However, the effects of smoking status on inguinal hernia repair outcomes have not been extensively studied. Hence, we investigated the association between smoking status and short-term adverse outcomes following inguinal hernia repair. METHODS: Abdominal Core Health Quality Collaborative database was queried for elective, clean inguinal hernia repairs, excluding those with concomitant procedures or where length of stay > 30 days. The resulting cohort was divided into three groups: current smokers, former smokers, and never smokers. Baseline patient, hernia, operative characteristics, and 30-day outcomes were compared. Multivariable logistic regression was used to evaluate the association between smoking status and overall and wound complications. RESULTS: 19,866 inguinal hernia repairs were included (current smokers = 2239, former smokers = 4064 and never smokers = 13,563). Current smokers and former smokers, compared to never smokers, had slightly higher unadjusted rates of overall complication rates (9% and 9% versus 7%, p = 0.003) and surgical site occurrences/infection (6% and 6% versus 4%, p < 0.001). However, on multivariable analysis, compared to current smokers, neither the rates of overall complications nor surgical site occurrences were significantly different in former smokers (OR = 0.93, 95% CI [0.76, 1.13] and OR = 0.92, 95% CI [0.73, 1.17]) and never smokers (OR = 0.99, 95% CI [0.83, 1.18] and OR = 0.86, 95% CI [0.70,1.06]) respectively. CONCLUSIONS: Smoking status is not associated with short-term adverse outcomes following inguinal hernia repair. Mandating smoking cessation does not appear necessary to prevent short-term adverse outcomes.

Process for quality assessment review of societal guidelines-an editorial to accompany "multi-society consensus conference and guideline on the treatment of gastroesophageal reflux disease (GERD)".

BACKGROUND: The SAGES Guidelines Committee has implemented processes for Quality Assessment of SAGES-endorsed guidelines, with the aim of improving the quality of published guidelines. METHODS: We provide details of the processes developed, using standardized tools for assessing the methodological quality of practice guidelines. As an example, we describe the application of our processes to the recent multi-societal GERD consensus guideline. RESULTS: Assessment of the multi-societal GERD consensus guideline by the iterative processes of SAGES Quality Assurance taskforce improved the quality of the final manuscript in all domains of appraisal. These processes are easily applicable to future guidelines. CONCLUSIONS: Such systems will increase the confidence in SAGES recommendations and increase the implementation of SAGES guidelines. By demonstrating the rigor of Quality Assessment, this confidence also extends to a further increase in the assurance of the publications of the Surgical Endoscopy journal.

Safety of Laparoscopic Appendectomy in the Setting of Coagulopathy: An ACS-NSQIP Study.

INTRODUCTION: Patients with coagulopathy requiring emergent appendectomy constitute a challenging patient population. It is unclear whether laparoscopic appendectomy (LA) is as safe as open appendectomy (OA) in these patients. METHODS: We queried the ACS-NSQIP database for adults with coagulopathy undergoing emergent appendectomy from 2014 to 2017. Demographic characteristics and operative outcomes were compared between the two groups. Propensity weighting for LA versus OA was estimated using augmented inverse probability of treatment weights (AIPW). RESULTS: A total of 137,429 patients were included, of which 7049 (5%) had coagulopathy. In patients with coagulopathy, LA was the most common approach (89%). After AIPW, there was no difference in the adjusted risk of either postoperative transfusion or 30-day reoperation between OA and LA. LA was associated with reduced operative time (56 versus 75 min), length of stay (3.5 versus 7.0 d), and surgical site infection rate (6% versus 13%) compared to OA. CONCLUSIONS: Patients with coagulopathy represent a significant proportion of those undergoing an appendectomy. The majority of patients with coagulopathy who require appendectomy undergo LA, and this approach appears to be safe with regard to transfusion requirement and reoperation.

Validation of a simple technique of volumetric analysis of complex incisional hernias without 3D CT scan reconstruction.

PURPOSE: Volumetric analysis is being increasingly utilized in the preoperative evaluation of complex incisional hernias. Three-dimensional (3D) reconstruction of abdominal computed tomography (CT) scan has been used to obtain surface area (SA) and volume (Vol.) measurements, while others have used simple mathematical formulas to obtain SA and Vol. estimates without 3D reconstruction. Our objective was to assess the correlation of SA and Vol. measurements and estimates of complex incisional hernias. METHODS: We conducted a retrospective agreement study of adults who underwent abdominal wall reconstruction from 2007 to 2018. Demographics, hernia characteristics, and operative data were collected from the medical record. SA and Vol. measurements were obtained after 3D CT reconstruction. Linear CT variables were obtained independently by two surgeons and SA and Vol. estimates were calculated. Because both surgeons reported similar results, only lead author values are reported in the abstract. We used Pearson's correlation coefficient (r) to assess inter-rater agreement and the agreement between SA and Vol. measurements and estimates. RESULTS: A total of 108 patients were eligible for analysis. The mean age was 57 ± 11 years and 53 (49%) were female. 42 (39%) hernias were recurrent, 10 (9%) patients had a stoma, and 9 (8%) had a history of open abdomen. The mean defect width was 11 ± 4 cm and mean defect surface area (DSA) was 150 ± 95 cm2. Inter-rater agreement of SA and Vol. estimates was high (r ≥ 0.80). There was high correlation between SA and Vol. measurements and estimates for DSA, hernia sac volume (HSV), abdominal cavity volume (ACV), and HSV/ACV ratio (r = 0.81, 0.89, 0.94 and 0.91, respectively). CONCLUSION: SA and Vol. estimates demonstrated high level of agreement with SA and Vol. measurements using 3D reconstruction. SA and Vol. estimates can be obtained using simple mathematical formulas using easily obtained linear variables negating the need for the time and effort consuming 3D reconstruction.

Safety of laparoscopic inguinal hernia repair in the setting of antithrombotic therapy.

INTRODUCTION: There are a paucity of data regarding the safety of laparoscopic inguinal hernia repair in patients on antiplatelet and anticoagulant therapy (APT/ACT). We aim to compare the postoperative outcomes of laparoscopic (LIHR) vs. open repair of inguinal hernias (OIHR) in patients on APT/ACT. METHOD: We conducted a retrospective cohort study using the Vizient Clinical DataBase. We included adults receiving APT/ACT who underwent outpatient, elective, and primary inguinal hernia repair between 2017 and 2019. Subgroup analysis was performed on patients receiving aspirin, non-aspirin antiplatelet, and anticoagulant therapy. Mixed-effects logistic regression was used to assess both the effect of APT/ACT on the probability of receiving LIHR vs OIHR and their respective outcomes. RESULT: A total of 142,052 repairs were included, of which 21,441 (15%) were performed on patients receiving APT/ACT. Mean age was 69 years (± 10.5) and 93% were male. 19% of hernias were bilateral. 40% of operations were performed at teaching hospitals. On multivariable analysis, patients on non-aspirin antiplatelet or anticoagulant therapy were more likely to receive an open procedure (Odds Ratio (OR) = 1.2; 95% Confidence Intervals (CI) [1.1, 1.4] and OR = 1.4; CI [1.3, 1.5], respectively). LIHR was associated with a lower rate of length of stay > 1 day (OR = 0.65; CI [0.5, 0.9]). Rates of 30-day postoperative hematoma, transfusions, stroke, myocardial infarction, deep venous thrombosis, pulmonary embolism, readmission, and emergency department visits were similar between the two operative approaches. CONCLUSION: Patients on APT/ACT represent a substantial proportion of those undergoing inguinal hernia repair. Non-aspirin antiplatelet or anticoagulant therapy are independent predictors of choosing an open repair. Laparoscopic repair appears to be safe in patients receiving APT/ACT under current perioperative management patterns.

SAGES TAVAC safety and efficacy analysis confocal laser endomicroscopy.

BACKGROUND: Confocal laser endomicroscopy (CLE) is a novel endoscopic adjunct that allows real-time in vivo histological examination of mucosal surfaces. By using intravenous or topical fluorescent agents, CLE highlights certain mucosal elements that facilitate an optical biopsy in real time. CLE technology has been used in different organ systems including the gastrointestinal tract. There has been numerous studies evaluating this technology in gastrointestinal endoscopy, our aim was to evaluate the safety, value, and efficacy of this technology in the gastrointestinal tract. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Technology and Value Assessment Committee (TAVAC) performed a PubMed/Medline database search of clinical studies involving CLE in May of 2018. The literature search used combinations of the keywords: confocal laser endomicroscopy, pCLE, Cellvizio, in vivo microscopy, optical histology, advanced endoscopic imaging, and optical diagnosis. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded. The manufacturer's website was also used to identify key references. The United States Food and Drug Administration (U.S. FDA) Manufacturer And User facility and Device Experience (MAUDE) database was searched for reports regarding the device malfunction or injuries. RESULTS: The technology offers an excellent safety profile with rare adverse events related to the use of fluorescent agents. It has been shown to increase the detection of dysplastic Barrett's esophagus, gastric intraepithelial neoplasia/early gastric cancer, and dysplasia associated with inflammatory bowel disease when compared to standard screening protocols. It also aids in the differentiation and classification of colorectal polyps, indeterminate biliary strictures, and pancreatic cystic lesions. CONCLUSIONS: CLE has an excellent safety profile. CLE can increase the diagnostic accuracy in a number of gastrointestinal pathologies.

Senior General Surgery Resident Confidence in Performing Abdominal Wall Hernia Repairs.

BACKGROUND: It is expected that graduating general surgery residents be confident in performing common abdominal wall hernia repairs. The objective of our study was to assess the confidence of senior surgical residents in these procedures and to identify factors that correlate with confidence. METHODS: We performed a cross-sectional survey of PGY-4 and PGY-5 general surgery residents at ACGME-accredited programs in the United States in the spring of 2019. Respondents rated their confidence level in 12 hernia procedures on a Likert scale from 1 (not confident) to 5 (extremely confident). Respondents were classified as "Not Confident" (Not Confident, Minimally Confident, Neutral responses) or "Confident" (Confident, Extremely Confident responses). Resident characteristics, program characteristics, and operative experience were collected, and we calculated the area under the curve to screen which factors discriminated between those confident versus not. Multivariable Poisson regression was used to estimate prevalence ratios (PR) and 95% confidence intervals (CI) to identify which factors were most predictive. RESULTS: A total of 93 surveys were completed. Respondents reported low confidence rates (25%-60%) in the following hernia repairs: minimally invasive (MIS) inguinal, femoral, tissue (nonmesh) inguinal, pediatric inguinal, and abdominal wall reconstruction. High confidence rates (>80%) were reported for open umbilical, open ventral, and MIS ventral hernia repairs. For MIS inguinal hernia repair, PGY-5 level was associated with a twofold increase in confidence (PR = 2.01; 95% CI = 1.34-3.30), and dedicated research years were associated with low confidence (PR = 0.67; 95% CI = 0.43-1.04). In general, higher operative volumes of a specific repair were associated with increased confidence in that procedure. CONCLUSIONS: Senior surgical residents reported low confidence in performing a variety of essential hernia repairs (particularly MIS inguinal, femoral, and tissue inguinal). Addressing factors associated with low confidence may help increase resident confidence.

Surgeon-performed endoscopic retrograde cholangiopancreatography. Outcomes of 2392 procedures at two tertiary care centers.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure that, in the United States, is traditionally performed by gastroenterologists. We hypothesized that when performed by well-trained surgeons, ERCP can be performed safely and effectively. The objectives of the study were to assess the rate of successful cannulation of the duct of interest and to assess the 30-day complication and mortality rates. METHODS: We retrospectively reviewed the charts of 1858 patients who underwent 2392 ERCP procedures performed by five surgeons between August 2003 and June 2016 in two centers. Demographic and historical data, indications, procedure-related data and 30-day complication and mortality data were collected and analyzed. RESULTS: The mean age was 53.4 (range 7-102) years and 1046 (56.3%) were female. 1430 (59.8%) of ERCP procedures involved a surgical endoscopy fellow. The most common indication was suspected or established uncomplicated common bile duct stones (n = 1470, 61.5%), followed by management of an existing biliary or pancreatic stent (n = 370, 15.5%) and acute biliary pancreatitis (n = 173, 7.2%). A therapeutic intervention was performed in 1564 (65.4%), a standard sphincterotomy in 1244 (52.0%), stent placement in 705 (29.5%) and stone removal in 638 (26.7%). When cannulation was attempted, the rate of successful cannulation was 94.1%. When cannulation was attempted during the patient's first ERCP the cannulation rate was 92.4%. 94 complications occurred (5.4%); the most common complication was post-ERCP pancreatitis in 75 (4.2%), significant gastrointestinal bleeding in 7 (0.4%), ascending cholangitis in 11 (0.6%) and perforation in 1 (0.05%). 11 mortalities occurred (0.5%) but none of which were ERCP-related. CONCLUSION: When performed by well-trained surgical endoscopists, ERCP is associated with high success rate and acceptable complication rates consistent with previously published reports and in line with societal guidelines.

Forecasting The Impact of the 2023 Current Procedural Terminology Coding Changes On Ventral Hernia Work Relative Value Units. A Cross-Sectional Study.

BACKGROUND: In January 2023, significant changes were implemented to ventral hernia repair Current Procedural Terminology codes, with new codes replacing previous codes. The new codes were assigned a 0-day global period. The impact of these changes on clinical productivity remains unclear. Our objective was to forecast the impact of Current Procedural Terminology changes on ventral hernia-related work relative value units using historical data. METHODS: Ventral hernia repairs performed between March 2021 and December 2022 on adults by a single surgeon with available 90-day follow-up were retrospectively retrieved from the Abdominal Core Health Quality Collaborative. Demographic, hernia, and operative and postoperative data were collected. The ventral hernia repairs were coded twice using the previous and new Current Procedural Terminology codes, and work relative value units were calculated using both systems. The median work relative value units per case were compared using the Wilcoxon signed-rank test. RESULTS: A total of 143 ventral hernia repairs were included. The median age was 59 years, and 50% of patients were male. Median hernia width and length were 3.5 and 5.0 cm, respectively. The most common ventral hernia types were incisional 57% and umbilical 33%. Twenty percent of hernias were recurrent, and 99% were elective repairs. 49% of the procedures were open, 30% robotic, and 21% laparoscopic. Component separation was performed in 16%. The median length of stay was 0.0, and the median number of 90-day outpatient postoperative visits was 1.0. The new Current Procedural Terminology coding system was associated with a higher median 90-day work relative value units per case (14.1) than the previous system (13.8) (P = .002). Subset analysis identified statistically higher median 90-day work relative value units per case using the new versus previous Current Procedural Terminology codes for hernias with the largest defect dimension >10 cm (23.3 vs 18.8), umbilical/epigastric/Spigelian hernias (9.2 vs 7.1), recurrent hernias (20.1 vs 17.3) and open ventral hernia repairs (9.8 vs 7.1), all P < .05. Median 90-day work relative value units per case were statistically lower using the new versus previous codes for non-recurrent (11.6 vs 13.8) and incarcerated/strangulated (14.8 vs 14.9) hernias, all P < .05. In the new coding system, postoperative care within 90-days contributed to a median of 1.3 work relative value units per case (9% of total 90-day work relative value units). CONCLUSION: We forecast that in our practice, the 2023 ventral hernia repair Current Procedural Terminology changes will result in a modest impact on clinical productivity. The impact of these changes on a particular practice depends on surgical practice patterns and ventral hernia case mix.

The association of hernia-specific and procedural risk factors with early complications in ventral hernia repair: ACHQC analysis.

BACKGROUND: Many surgical risk assessment tools emphasize patient-specific risk factors. Our objective was to use a hernia-specific database to assess risk factors of complications in ventral hernia repair (VHR) focusing on hernia-specific and procedural factors. METHODS: The ACHQC database was queried for elective VHR in adults from 2012 to 2023. Primary outcome was overall 30-day complications. Multivariable logistic regression was used for analysis. RESULTS: 41,526 VHR were included. The rate of 30-day complications was 18%, surgical site infection 3%, surgical site occurrence requiring procedural intervention 4%, readmission 4%, reoperation 2%, and mortality 0.2%. Multivariable analysis demonstrated that BMI, ASA, frailty, COPD, anticoagulants, defect width, incisional and recurrent hernias, presence of stoma or prior mesh, prior abdominal wall infection, non-clean wound, operative time, open approach and myofascial release were associated with 30-day complications (OR â€‹= â€‹1.01-1.66). Preoperative chlorhexidine, bowel preparation and fascial closure were associated with lower complication risk (OR â€‹= â€‹0.70-0.89). CONCLUSION: Hernia and procedural risk factors are associated with early complications following elective VHR. These factors need to be included in surgical risk assessment tools, to supplement patient-specific factors.

A narrative review of ergonomic problems, principles, and potential solutions in surgical operations.

BACKGROUND: Ergonomic development and awareness are critical to the long-term health and well-being of surgeons. Work-related musculoskeletal disorders affect an overwhelming majority of surgeons, and various operative modalities (open, laparoscopic, and robotic surgery) differentially affect the musculoskeletal system. Previous reviews have addressed various aspects of surgical ergonomic history or methods of ergonomic assessment, but the purpose of this study is to synthesize ergonomic analysis by surgical modality while discussing future directions of the field based on current perioperative interventions. METHODS: pubmed was queried for "ergonomics," "work-related musculoskeletal disorders," and "surgery," which returned 124 results. From the 122 English-language papers, a further search was conducted via the articles' sources for relevant literature. RESULTS: Ninety-nine sources were ultimately included. Work-related musculoskeletal disorders culminate in detrimental effects ranging from chronic pain and paresthesias to reduced operative time and consideration for early retirement. Underreporting symptoms and a lack of awareness of proper ergonomic principles substantially hinder the widespread utilization of ergonomic techniques in the operating room, reducing the quality of life and career longevity. Therapeutic interventions exist at some institutions but require further research and development for necessary widespread implementation. CONCLUSION: Awareness of proper ergonomic principles and the detrimental effects of musculoskeletal disorders is the first step in protecting against this universal problem. Implementing ergonomic practices in the operating room is at a crossroads, and incorporating these principles into everyday life must be a priority for all surgeons.

Internal Hernia After Laparoscopic Antecolic Roux-en-Y Gastric Bypass.

BACKGROUND: We evaluated the incidence and presentations of internal hernias (IH) after laparoscopic antecolic Roux-en-Y gastric bypass (RYGB) at our institution. METHODS: We retrospectively reviewed the records of 594 patients who underwent laparoscopic antecolic RYGB at our institution between December 2004 and December 2010. RESULTS: Five hundred ninety-four patients underwent laparoscopic antecolic RYGB with a mean follow-up of 50.5 months. Thirty-six patients developed 37 IH (6.2 %) requiring surgical intervention. Mean age of IH patients was 36.9 years. Thirty-one out of 36 were female. Mean preoperative BMI was 44.3 Kg/m(2). The mean time of presentation after their RYGB was 25.9 months. The mean % excess body weight loss at time of presentation was 54.0 %. Twenty-five out of 37 of IH occurred at Petersen's space; 9/37 IH occurred under the jejunojejunostomy; three patients had hernias at both locations. Mesenteric swirling was the most common CT scan finding in 20/36 (55.6 %). Six out of 36 CT were initially read as normal; however, on retrospective review by a radiologist, abnormalities indicating IH were found in 4/6. Patients presented with different degrees of acuity: 6/37 with chronic abdominal pain and 28/37 with acute abdominal pain. Bowel necrosis was found in 3/37. CONCLUSION: IH is a serious and potentially fatal complication of RYGB. Presentation can vary from chronic abdominal pain to bowel necrosis. CT is helpful in providing diagnosis; however, careful attention to the specific signs of small bowel volvulus, such as mesenteric swirl sign, should be given. IH should be considered in RYGB patients who present with even vague symptoms.