Prevention and management of internal hernias after bariatric surgery: an expert review

Abstract

Internal hernia formation is a feared complication following bariatric surgery. Protrusion of the small bowel through mesenteric defects can result in volvulus presenting with symptoms of bowel obstruction. If left untreated, patients may go on to develop bowel ischemia with possible perforation or necrosis necessitating emergent surgical exploration with resection. In severe cases, extensive bowel resection is required, leading to short-gut syndrome, which can have devastating consequences for the already nutritionally vulnerable bariatric patient. This review presents a comprehensive summary of various surgical techniques and technical factors implicated in the formation of internal hernias. The clinical presentation of patients with internal hernias, appropriate diagnostic work-up, and effective management and treatment strategies are discussed based on the established literature.

Keywords

Internal hernia / bariatric surgery / bowel obstruction

References

[1] Moose D,Powell W.Laparoscopic Roux-en-Y gastric bypass: minimally invasive bariatric surgery for the superobese in the community hospital setting.Am Surg2003;69:930-2

[2] Higa KD,Ho T.Laparoscopic Roux-en-Y gastric bypass for morbid obesity: technique and preliminary results of our first 400 patients.Arch Surg2000;135:1029-33; discussion 1033

[3] Papasavas PK,Caushaj PF.Outcome analysis of laparoscopic Roux-en-Y gastric bypass for morbid obesity. The first 116 cases.Surg Endosc2002;16:1653-7

[4] Sjöström L,Peltonen M.; Swedish Obese Subjects Study Scientific Group. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery.N Engl J Med2004;351:2683-93

[5] ASMBS. Estimate of bariatric surgery numbers, 2011-2019. Available from: https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers [Last accessed on 17 Mar 2022]

[6] Kang JH.Effectiveness of bariatric surgical procedures: a systematic review and network meta-analysis of randomized controlled trials.Medicine (Baltimore)2017;96:e8632 PMCID:PMC5704829

[7] Escalona A,Pérez G.Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study.Surg Obes Relat Dis2007;3:423-7

[8] Cho M,Carrodeguas L.Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases.Surg Obes Relat Dis2006;2:87-91

[9] Geubbels N,Fiocco M,Wouters MW.Meta-analysis of internal herniation after gastric bypass surgery.Br J Surg2015;102:451-60

[10] Rodríguez A,Sierra M.Small bowel obstruction after antecolic and antegastric laparoscopic Roux-en-Y gastric bypass: could the incidence be reduced?.Obes Surg2010;20:1380-4

[11] Sethi M,Youn A,Fielding G.Long-term outcomes after biliopancreatic diversion with and without duodenal switch: 2-, 5-, and 10-year data.Surg Obes Relat Dis2016;12:1697-705

[12] Smith SC,Goodman GN,Simper SC.Open vs laparoscopic Roux-en-Y gastric bypass: comparison of operative morbidity and mortality.Obes Surg2004;14:73-6

[13] Luján JA,Hernández Q.Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study.Ann Surg2004;239:433-7 PMCID:PMC1356246

[14] Westling A.Laparoscopic vs open Roux-en-Y gastric bypass: a prospective, randomized trial.Obes Surg2001;11:284-92

[15] Capella RF,Capella JF.Bowel obstruction after open and laparoscopic gastric bypass surgery for morbid obesity.J Am Coll Surg2006;203:328-35

[16] Schneider C,Scott J,Myers K.Rapid excess weight loss following laparoscopic gastric bypass leads to increased risk of internal hernia.Surg Endosc2011;25:1594-8

[17] Gunabushanam G,Czerniach DR,Perugini RA.Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass surgery.J Comput Assist Tomogr2009;33:369-75

[18] Husain S,Johnson J,O'Malley W.Small-bowel obstruction after laparoscopic Roux-en-Y gastric bypass: etiology, diagnosis, and management.Arch Surg2007;142:988-93

[19] Comeau E,Inabnet WB,Quinn TM.Symptomatic internal hernias after laparoscopic bariatric surgery.Surg Endosc2005;19:34-9

[20] Filip JE,Bowers SP.Internal hernia formation after laparoscopic Roux-en-Y gastric bypass for morbid obesity.Am Surg.2002;68:640-3

[21] Champion JK.Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass.Obes Surg2003;13:596-600

[22] Garza E Jr,Arnold D,Reddy S.Internal hernias after laparoscopic Roux-en-Y gastric bypass.Am J Surg2004;188:796-800

[23] Nguyen NT,Gelfand D,Jim J.Bowel obstruction after laparoscopic Roux-en-Y gastric bypass.Obes Surg2004;14:190-6

[24] Obeid A,Breland M,Clements RH.Internal hernia after laparoscopic Roux-en-Y gastric bypass.J Gastrointest Surg2014;18:250-5; discussion 255

[25] Paroz A,Giusti V.Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery.Obes Surg2006;16:1482-7

[26] Higa KD,Boone KB.Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention.Obes Surg2003;13:350-4

[27] Al-Mansour MR,Canoy JM,Kuhn JN.Internal hernia after laparoscopic antecolic Roux-en-Y gastric bypass.Obes Surg2015;25:2106-11

[28] Aghajani E,Nergaard BJ,Leifson BG.Internal hernia after gastric bypass: a new and simplified technique for laparoscopic primary closure of the mesenteric defects.J Gastrointest Surg2012;16:641-5 PMCID:PMC3274684

[29] Onopchenko A.Radiological diagnosis of internal hernia after Roux-en-Y gastric bypass.Obes Surg2005;15:606-11

[30] Lockhart ME,Canon CL.Internal hernia after gastric bypass: sensitivity and specificity of seven CT signs with surgical correlation and controls.AJR Am J Roentgenol2007;188:745-50

[31] D'Haeninck A,Swinnen F.Internal herniation after Roux-en-Y gastric bypass: case reports and a review of the literature.Acta Chir Belg2009;109:385-91

[32] Scheirey CD,Shah PC,Wong BB.Radiology of the laparoscopic Roux-en-Y gastric bypass procedure: conceptualization and precise interpretation of results.Radiographics2006;26:1355-71

[33] McAllister MS,Lucktong TA.Synchronous intussusceptions following Roux-en-Y Gastric Bypass: case report and review of the literature.Obes Surg2009;19:1719-23

[34] Bauman RW.Internal hernia at Petersen's space after laparoscopic Roux-en-Y gastric bypass: 6.2% incidence without closure--a single surgeon series of 1047 cases.Surg Obes Relat Dis2009;5:565-70

[35] Felsher J,Brody F.Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass.Surgery2003;134:501-5

[36] Quebbemann BB.The orientation of the antecolic Roux limb markedly affects the incidence of internal hernias after laparoscopic gastric bypass.Obes Surg2005;15:766-70; discussion 770

[37] Bakker JK, van Namen YW, Bruin SC, de Brauw LM. Gastric bypass and abdominal pain: think of Petersen hernia.JSLS2012;16:311-3 PMCID:PMC3481246

[38] Blachar A.Gastrointestinal complications of laparoscopic roux-en-Y gastric bypass surgery in patients who are morbidly obese: findings on radiography and CT.AJR Am J Roentgenol2002;179:1437-42

[39] Nawas MA,Goense L.The diagnostic accuracy of abdominal computed tomography in diagnosing internal herniation following Roux-En-Y gastric bypass surgery: a systematic review and meta-analysis.Ann Surg2021;

[40] Torensma B,Liem R,Swank DJ.Internal herniation incidence after RYGB and the predictive ability of a ct scan as a diagnostic tool.Obes Surg2021;31:127-32 PMCID:PMC7808966

[41] Høgestøl IK,Eribe I.Chronic abdominal pain and symptoms 5 years after gastric bypass for morbid obesity.Obes Surg2017;27:1438-45

[42] Geubbels N,Acherman YI,van de Laar AW.Internal herniation after laparoscopic roux-en-y gastric bypass surgery: pitfalls in diagnosing and the introduction of the Amsterdam classification.Obes Surg2016;26:1859-66

[43] Karcz WK,Daoud M.Modification of internal hernia classification system after laparoscopic Roux-en-Y bariatric surgery.Wideochir Inne Tech Maloinwazyjne2015;10:197-204 PMCID:PMC4520845

[44] Aman MW,Magnuson TH. Intestinal complications after Roux-en-Y gastric bypass. Available from: https://bariatrictimes.com/intestinal-complications-after-roux-en-y-gastric-bypass/ [Last accessed on 17 Mar 2022]

[45] Spector D,Shah S,Tarnoff ME.Roux-en-Y gastric bypass: hyperamylasemia is associated with small bowel obstruction.Surg Obes Relat Dis2015;11:38-43

[46] Leyba JL,Navarrete Llopis S,Gamboa A.Laparoscopic technique for hernia reduction and mesenteric defect closure in patients with internal hernia as a postoperative complication of laparoscopic Roux-en-Y gastric bypass.Surg Laparosc Endosc Percutan Tech2012;22:e182-5

[47] Nimeri AA,Al Shaban T,Gamaleldin MM.Internal hernia following laparoscopic Roux-en-Y gastric bypass: prevention and tips for intra-operative management.Obes Surg2016;26:2255-6

[48] Gandhi AD,Brolin RE.Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass.Surg Obes Relat Dis2009;5:144-9; discussion 149

[49] Blachar A,Pealer KM,Schauer PR.Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings.Radiology2002;223:625-32

[50] Stenberg E,Ågren G.Closure of mesenteric defects in laparoscopic gastric bypass: a multicentre, randomised, parallel, open-label trial.Lancet2016;387:1397-404

[51] Abasbassi M,Deylgat B.Small bowel obstruction after antecolic antegastric laparoscopic Roux-en-Y gastric bypass without division of small bowel mesentery: a single-centre, 7-year review.Obes Surg2011;21:1822-7

[52] la Cruz-Muñoz N, Cabrera JC, Cuesta M, Hartnett S, Rojas R. Closure of mesenteric defect can lead to decrease in internal hernias after Roux-en-Y gastric bypass.Surg Obes Relat Dis2011;7:176-80

[53] Garrard CL,Nanney L,Richards WO.Adhesion formation is reduced after laparoscopic surgery.Surg Endosc1999;13:10-3

[54] Nandipati KC,Husain F,Sweeney JF.Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB).J Gastrointest Surg2012;16:675-81

[55] Madan AK,Dhawan N.Internal hernias and nonclosure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass.Obes Surg2009;19:549-52

[56] Finnell CW,Tichansky DS,Taddeucci R.Non-closure of defects during laparoscopic Roux-en-Y gastric bypass.Obes Surg2007;17:145-8

[57] Kristensen SD,Naver L,Floyd AK.Randomized clinical trial on closure versus non-closure of mesenteric defects during laparoscopic gastric bypass surgery.Br J Surg2021;108:145-51

[58] Rosas U,Leva N.Mesenteric defect closure in laparoscopic Roux-en-Y gastric bypass: a randomized controlled trial.Surg Endosc2015;29:2486-90

[59] Chowbey P,Kantharia NS,Sharma A.Mesenteric defect closure decreases the incidence of internal hernias following laparoscopic Roux-En-Y gastric bypass: a retrospective cohort study.Obes Surg2016;26:2029-34

[60] Aghajani E,Leifson BG,Gislason H.The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique.Surg Endosc2017;31:3743-8 PMCID:PMC5579176

[61] Amor IB,Debs T.Impact of mesenteric defect closure during laparoscopic Roux-En-Y gastric bypass (lrygb): a retrospective study for a total of 2093 LRYGB.Obes Surg2019;29:3342-7

[62] Blockhuys M,Heyman S,van Sprundel F.Internal hernia after laparoscopic gastric bypass: effect of closure of the petersen defect - single-center study.Obes Surg2019;29:70-5

[63] Lopera CA,Cabrera LF.Preventative laparoscopic repair of Petersen's space following gastric bypass surgery reduces the incidence of Petersen's hernia: a comparative study.Hernia2018;22:1077-81

[64] Carmody B,Jamal M.Internal hernia after laparoscopic Roux-en-Y gastric bypass.Surg Obes Relat Dis2005;1:543-8

[65] Hope WW,Chen AY.Failure of mesenteric defect closure after Roux-en-Y gastric bypass.JSLS2010;14:213-6 PMCID:PMC3043570

[66] Schauer PR.Laparoscopic surgery for morbid obesity.Surg Clin North Am2001;81:1145-79

[67] Magouliotis DE,Tasiopoulou VS,Zacharoulis D.Closure of mesenteric defects in laparoscopic gastric bypass: a Meta-Analysis.Obes Surg2020;30:1935-43

[68] Hwang RF,Felix EL.Causes of small bowel obstruction after laparoscopic gastric bypass.Surg Endosc2004;18:1631-5

[69] Shikora SA,Tarnoff ME,Shore R.Laparoscopic Roux-en-Y gastric bypass: results and learning curve of a high-volume academic program.Arch Surg2005;140:362-7

[70] Eckhauser A,Youssef Y,Richards WO.Internal hernia: postoperative complication of roux-en-Y gastric bypass surgery.Am Surg2006;72:581-4; discussion 584

[71] Yang J,Huang S.Different surgical techniques that influenced internal hernia prevalence rate after laparoscopic roux-en-Y gastric bypass: a retrospective analysis of 331 cases.BMC Surg2020;20:48 PMCID:PMC7077004

[72] Iannelli A,Novellas S.Internal hernia as a complication of laparoscopic Roux-en-Y gastric bypass.Obes Surg2007;17:1283-6

[73] Coleman MH,Pomp A.Laparoscopic closure of the Petersen mesenteric defect.Obes Surg2006;16:770-2

[74] Stenberg E,Szabo E.Comparing techniques for mesenteric defects closure in laparoscopic gastric bypass surgery-a register-based cohort study.Obes Surg2019;29:1229-35

[75] Love MW,Hale AL.Use of bioabsorbable tissue reinforcement reduces incidence of internal hernia in Roux-en-Y gastric bypass patients.Am Surg2018;84:1756-61

[76] Skidmore A.Preventing peterson's space hernia using a BIO synthetic mesh.BMC Surg2021;21:236 PMCID:PMC8097920

[77] Müller MK,Wildi S,Clavien PA.Three-year follow-up study of retrocolic versus antecolic laparoscopic Roux-en-Y gastric bypass.Obes Surg2007;17:889-93

[78] Harakeh AB, Kallies KJ, Borgert AJ, Kothari SN. Bowel obstruction rates in antecolic/antegastric versus retrocolic/retrogastric Roux limb gastric bypass: a meta-analysis.Surg Obes Relat Dis2016;12:194-8

[79] Ahmed AR,Husain S,Boss T.Trends in internal hernia incidence after laparoscopic Roux-en-Y gastric bypass.Obes Surg2007;17:1563-6

[80] Quezada N,Jones A.High frequency of internal hernias after Roux-en-Y gastric bypass.Obes Surg2015;25:615-21

[81] Taylor JD,Rosser JB,Goodman E.Does the position of the alimentary limb in Roux-en-Y gastric bypass surgery make a difference?.J Gastrointest Surg2006;10:1397-9

[82] Kassir R,Blanc P.Complications of bariatric surgery: Presentation and emergency management.Int J Surg2016;27:77-81

[83] Surve A,Sanchez-Pernaute A.The incidence of complications associated with loop duodeno-ileostomy after single-anastomosis duodenal switch procedures among 1328 patients: a multicenter experience.Surg Obes Relat Dis2018;14:594-601

[84] Rheinwalt KP,Rückbeil MV,Neumann UP.One Anastomosis gastric bypass-mini-gastric bypass (OAGB-MGB) versus Roux-en-Y gastric bypass (RYGB)-a mid-term cohort study with 612 Patients.Obes Surg2020;30:1230-40

[85] Kermansaravi M,Pazouki A.Petersen's space internal hernia after laparoscopic one anastomosis (mini) gastric bypass.Case Rep Surg2018;2018:9576120 PMCID:PMC5901483

[86] Khogeer A,Adamo M.Internal hernia after laparoscopic one-anastomosis (mini) gastric bypass: video case series of a single-center experience.Obes Surg2021;31:2839-40

[87] Facchiano E,Lucchese M.Laparoscopic Management of internal hernia after one anastomosis gastric bypass (OAGB).Obes Surg2020;30:4169-70

[88] Summerhays C,Cottam A.Internal hernia after revisional laparoscopic loop duodenal switch surgery.Surg Obes Relat Dis2016;12:e13-5

[89] Petrucciani N,Kassir R.Internal hernia after one anastomosis gastric bypass (OAGB): lessons learned from a retrospective series of 3368 consecutive patients undergoing OAGB with a biliopancreatic limb of 150 cm.Obes Surg2021;31:2537-44 PMCID:PMC8113202