Internal Hernia After Laparoscopic Gastric Bypass Without Preventive Closure of Mesenteric Defects: a Single Institution's Experience.

BACKGROUND: Internal herniation (IH) is a well-known complication after laparoscopic gastric bypass (LGB). Diagnosing and managing IH can be challenging. This retrospective cohort study aimed to achieve a greater understanding of symptomatology, diagnostic tools, complications, risk of IH recurrence, and symptom relief in IH patients. METHODS: We included patients who underwent LGB surgery at our institution between 2011 and 2015. Mesenteric defects were not preventively closed during LGB. We focused on LGB patients who underwent surgical intervention(s) for suspected IH during a 7-year study period. We studied patient characteristics, (predictive) symptoms and signs, abdominal imaging, operative findings, post-operative course, and risk of (recurrent) IH. RESULTS: A total of 1588 patients were included. In total, 243 patients underwent IH-related diagnostic laparoscopy. Radiating pain to the back (OR 2.45, p = .03), post-prandial pain (OR 3.23, p = .00), and leukocytosis (OR 15.53, p = .01) were identified as predictors of IH. The estimated risk of IH-related diagnostic laparoscopy was 16% at 3 years post-LGB, and the risk of confirmed IH was 12%. The estimated risk of diagnostic laparoscopy for suspected recurrent IH was 10% at 5 years post-LGB. In patients who underwent secondary mesenteric defects closure, post-operative symptom relief was reported in 84%. CONCLUSION: This study demonstrates a considerable risk of developing IH after LGB without preventive closure of the mesenteric defects. We emphasize the value of diagnostic laparoscopy to achieve symptom relief in patients with suspicion of IH. Preoperative diagnosis of IH can be improved by being watchful of specific symptoms and signs which can predict the intra-operative presence of IH.

Simultaneous Large Paraesophageal Hernia Repair and Laparoscopic Roux-en-Y Gastric Bypass: a Single Institution's Experience.

This study reviews a single institution's experience with simultaneous (redo) laparoscopic Roux-en-Y gastric bypass (LRYGB) and primary large paraesophageal hernia (PEH) repair. A retrospective review was done of all 13 patients who underwent simultaneous LRYGB and large PEH repair between February 2014 and December 2017 at our institution. All patients had a large type III or IV PEH. All patients underwent primary crural repair, without the use of a reinforcing mesh. No patients underwent additional surgery for obstruction of the gastric pouch or for symptomatic recurrence of PEH. No mortality was reported. Our study highlights that simultaneous primary large PEH repair and primary or redo LRYGB is safe and feasible.