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Internal Hernia after Laparoscopic Gastric Bypass: A Review of the Literature

| April 26, 2007

by Louis O. Jeansonne IV, MD; Craig B. Morgenthal, MD; Brent C. White, MD; and Edward Lin, DO

All from Emory Endosurgery Unit, Emory University School of Medicine

Laparoscopic Roux-en-Y gastric bypass (LGBP) has been shown to be an effective treatment for morbid obesity, both in terms of weight loss and improvement in multiple comorbidities. 1 While the laparoscopic approach offers many advantages to the patient in terms of fewer wound complications, decreased length of hospital stay, and decreased postoperative pain, certain complications of this operation continue to pose difficult clinical problems as the number of procedures performed increases. One such complication is internal hernia through one of the mesenteric defects, which can result in small bowel obstruction, ischemia, or infarction and often requires reoperation.

An internal hernia is defined as a protrusion of intestine through a defect within the peritoneal cavity, as opposed to an external (or incisional) hernia that protrudes through all layers of the abdominal wall.2 Internal hernias almost always occur through iatrogenic defects created surgically.

Incisional hernias occur at a higher incidence after open gastric bypass (GBP) at a rate of about 20 percent.3 LGBP has a lower rate of incisional hernias. A recent study by Rosenthal, et al., showed a 0.2-percent rate of port site hernias in 849 patients using blunt-tip trocars at 3,744 port sites.4

Internal hernias, on the other hand, occur more frequently in LGBP than in the open procedure. This is a significant clinical problem, since internal hernia is the most common cause of small bowel obstruction (SBO) after LGBP. Retrospective reviews have found the incidence of SBO after LGBP to be between 1.8 and 9.7 percent.5-8 The purpose of this review is to evaluate the incidence and management of internal hernias (with or without SBO) after LGBP. The incidence of internal hernia after LGBP is between 0.2 and 8.6 percent based on multiple studies (Table 1). This incidence is higher than that seen with open GBP, and this is presumably due to decreased adhesion formation after laparoscopic surgery compared to open surgery.9 The creation of potential space as a result of weight loss may also be a contributing factor in the etiology of internal hernias, which often present in a delayed fashion. In addition, the particular case of pregnancy— with the mass effect of an enlarging uterus—may predispose to this condition, as there have been three case reports in the literature of internal hernia during pregnancy, one of which resulted in intestinal ischemia and fetal demise.10,11 Due to the increasing scope of this problem and its potentially devastating consequences, surgeons should have a high clinical suspicion for internal hernia after LGBP.

An internal hernia can potentially occur through either two or three defects, depending on whether a retrocolic or antecolic technique is used for the Roux limb (Figure 1). Petersen’s defect is defined as the space between the Roux limb and the transverse mesocolon. A defect is also present between the biliopancreatic and Roux limbs at the jejunojejunostomy. If a retrocolic approach is used, a third defect in the transverse mesocolon is created. This is the most common site of internal hernia in most reports,8,18,20,22 which has prompted many surgeons to adopt an antecolic technique in order to eliminate this defect. Higa’s study of 2,000 patients showed an internal hernia distribution of 67 percent mesocolic, 21 percent jejunal, and 7.5 percent Petersen.20 However, some centers experience a higher rate of hernia in the jejunal or Petersen’s defects, despite the use of a retrocolic approach.5,12

PRESENTATION Patients with internal hernia most commonly present with abdominal pain, and may also have symptoms of small bowel obstruction. The time of presentation varies greatly and may occur within one week of the initial operation or up to three years postoperatively. However, the majority of cases occur between 6 and 24 months postoperative.5 Radiographic diagnosis of internal hernia presents a challenge since the characteristic findings on computed tomography (CT) scan are often missed. Features suggestive of an internal hernia include small bowel loops in the upper quadrants; evidence of small bowel mesentery crossing the transverse mesocolon; presence of the jejunojejunostomy superior to the transverse colon; signs of small bowel obstruction; or twisting, swirling, crowding, stretching, or engorgement of the main mesenteric trunk (Figures 2 and 3).24 According to one study, the sensitivity and specificity of CT is 63 percent and 76 percent, respectively.24 Another study showed that although the diagnosis was only made prospectively by CT scan in 64 percent of cases, a retrospective review of the images showed that diagnostic abnormalities were present in 97 percent of cases.18 A report of five cases of internal hernia by Onopchenko found that only one was diagnosed preoperatively by radiological reading, even though all five had findings suggestive of internal hernia to the bariatric surgeon.25 These findings emphasize the need for communication with the radiologist, careful attention to patient history, and high clinical suspicion for internal hernias. In rare cases, closed loop obstruction and extensive bowel ischemia and infarction can occur. This dreaded complication underscores the necessity of making a rapid diagnosis. If the patient has significant symptoms but radiologic studies are negative, a diagnostic laparoscopy is warranted to rule out internal hernia.

PREVENTION AND TREATMENT Given the prevalence of internal hernias and the increasing popularity of bariatric surgery, it is important to prevent or minimize this complication at the time of the initial operation. Although there have been no randomized, controlled trials comparing different techniques of LGBP, some authors have anecdotally reported lower rates of internal hernia after modifying their technique from a retrocolic to antecolic approach.6,7 Champion and Williams reported a significant decrease in small bowel obstruction after changing to an antecolic position, and Felsher and colleagues found no internal hernias in their study after adopting the antecolic approach.6,7 However, other studies support careful defect closure as the most important factor in reducing hernia rates.12,14,15 Dresel and colleagues report no internal hernias after modifying their technique to include closure of Petersen’s defect.15 Carmody and colleagues report a decreased hernia incidence when closing all defects, even with a retrocolic approach.12 DeMaria’s study reports anecdotal improvement after closing mesenteric defects in two layers, on the medial and lateral aspects of the defect.14

As seen in Table 1, a review of the literature shows a general trend toward lower rates of internal hernia with antecolic compared to retrocolic, and with defect closure compared to non-closure. However, rates of internal hernias still remain variable among different bariatric centers, suggesting that other factors besides mesenteric closure and Roux limb position may affect outcomes.

The majority of internal hernias can be successfully treated laparoscopically, with reduction and defect closure. Our approach to these cases begins by placing a supraumbilical 12mm trocar for the laparoscope and two lateral 5mm ports for graspers to begin the exploration. This provides access to all three potential defects. The laparoscopic approach is usually successful; however, because of the lack of adhesion formation after laparoscopy, Capella, et al., suggest laparotomy for patients who experience a second episode of bowel obstruction due to recurrent internal hernia after laparoscopic repair.5 The greater adhesion formation after laparotomy may help prevent future internal hernia formation.

CONCLUSION One of the benefits of laparoscopy, decreased adhesion formation, is likely also responsible for the increasing prevalence of internal hernia as a complication following laparoscopic gastric bypass. Although it has not been borne out in randomized clinical trials, anecdotal evidence and expert opinion suggest that Roux limb position and mesenteric defect closure at the time of initial operation are important factors in ultimate rates of hernia formation. Careful attention must be paid to individual surgical techniques in order to prevent this potentially devastating complication. The benefits of LGBP are maximized when there is a low incidence of postoperative hernias and resultant obstruction.

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Ann Surg 2002;235(5):640–5; discussion
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21. Nelson LG, Gonzalez R, Haines K, et al.
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22. Papasavas PK, Caushaj PF, McCormick JT, et al.
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morbid obesity. Surg Endosc 2003;17(4):610–4.
23. Suter M, Giusti V, Heraief E, et al. Laparoscopic
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24. Blachar A, Federle MP, Brancatelli G, et al.
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CORRESPONDING AUTHOR:
Louis O. Jeansonne IV, MD,
1364 Clifton Road NE, Suite,
H124, Atlanta, Georgia 30322;
Phone: 404.727.9665;
Fax: 404.712.2739;
E-mail:
Louis.Jeansonne@emoryhealthcare.orgia with morbidly

Category: Surgical Perspective

Comments (17)

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  1. Mary Ann says:

    Wow, explains what has happened to me and why. I have a surgical consult in the next week for this issue. My original surgeon has practically turned his back on me and told me that I was imagining the pain and issues. I recently moved to another state and got a new Dr, they had a CT done and found the internal hernia.

  2. karen says:

    In my case, I experienced two internal hernias with small bowel obstruction. I went to my local hospital emergency room. I had severe abdominal pain, severe abdominal distention, and vomiting fecal matter. I was misdiagnosed with an ulcer. The doctor had complete medical history of LPGB. I was there for nine days with the same symptoms. They were going to release me to go home, but my family transported me to my LPGB hospital 45 minutes away. I was feverish and sepcis. They did a
    CT scan and emergent surgery for SBO and internal hernia repair. Unfortunately, because I was misdiagnosed I was to the point of death. The small bowel was gangrene and perforated. I had a myocarlial infarction (heart attack), hypoxic respitory failure, and deep vein thrombosis. It is a miracle that I survived. I now, one year later, am still fighting for my life. I have severe steatorrhea(diarrhea with unabsorbed fat), malabsorbtion, which can be fatal. My internal hernias occured 24 months after LPGB It is so important to reach the doctors and patients to be very diligent to recognize the symptoms of this complication, and it’s importance for expeditious surgery and better diagnosis.

  3. Susan says:

    I was also misdiagnosed. I had an internal herniation about four years after GBS. I had no pain at all. I was extremely lethargic and could barely walk. I went to ER and was sweating profusely. While they were testing me for a heart attack, I had several bowel movements that were foul smelling and very loose. I began to feel better. They sent me home with a diagnoses of gastritis. I followed up with my doc who sent me to the ER after hearing no bowel sounds. There I was diagnosed with pancreatitis. I ended up in surgery. My abdominal cavity had three liters of bile

  4. Susan says:

    and necrotic intestine. They pumped 90 lbs. of fluid in me during surgery. I developed ARDS and sepsis. I was in ICU for five weeks and on the surgical floor another. I was on a respeirator for four weeks and I had a near death experience. All of this with no abdominal pain. My surgeon said it was a miracle I survived. I agree.

  5. Barry says:

    Thank you for the information. Had experienced such pain intermittently (1 a month) for over a year but it would just dissipate and never went for a consult. So stupid. Finally, a debilitating episode sent me to the emergency room but before I got there, all pain dissipated so I felt embarrassed to be there. However, since I thought it might be tied to my LGBP 2+years ago, I asked to be taken to the hospital associated with the LGBP. Only because bariatric specialists were around was it possible to diagnose and happily will get it treated. Please get examined if you feel abdominal pain.

  6. Beth says:

    I had severe pain and distended abdomen in the upper left quadrant. After several hours of thinking “this too shall pass” I called the bariatric center and went to the ER. The CT was negative, and they suspected a gall bladder issue. Ultrasound showed some “sludge” and small “sand” however no “aha” moment. An EGD showed no ulcer. After multiple pain meds with minimal relief, 2 days in the hospital and they performed another laproscopy and found 2 areas of hernia, one strangulated. My doc told me that I was very lucky, one more day and I would have been in critical condition with necrotic bowels. Listen to your body – if I doesn’t feel right, get attention immediately. My hernia was 14 months post GBP.

  7. Nancy says:

    I had LPGB 2 years ago. I have lost 190lbs. It was the best decision I made for my health. Just three weeks ago I went to the ER with severe abdomnial pain. I am a registered nurse and thought it was just bad gas. Found out quickly that I had an internal hernia and an ischemic bowel. I had emergency surgery to take care of it and have recovered wonderfully. The surgeon happened to be a partner to the doctor that did my LPGB. They were wonderful and amazing at diagnosing me and getting it done. Other than this I have had NO issues at all with my LPGB. There are amazing surgeons out there and doctors that really do “know” there stuff. I am glad I had the weight loss surgery. I am a different women.

  8. Sterl says:

    I had LPGB in March of 2007,Done great till 3-15-2011 and had a sever pain hit me in my lower stomich and through to my back.I thought i would die from the pain nothing would touch my pain.So to make a long story short was quickley taken to the Er room where they were sure i was having another heart attack,But theat was quickely found to be false.Was sent to the heart center then quickely sent to the Baraitric hospital wher i had my LPGB done,Rushed into surgery to find i had a internal Hernia that had wraped around my small intestine and caused it to die off.also had a large bowel blockage,I want everyone to know you can still have bowel movements and things seem to be going ok.BUT if your stomich starts hurting after meals then lets up and your bowel movements starts to smell horriable…..Please please run to the Dr.where you had your surgery not your family Dr. You are just waisting vital time,Your surgeons if they are on top of all these things that can happen so long after surgery,Will know just what is going on.If i had not listened to my wife and went when i did i would have been dead today.My surgeon told me the The hernia had been there for a while and had slowely wraped its self around my small intestine then finally cut off blood flow to the bowel and set in gangreen i am one thankful guy that God chose to allow me some more time here,I know how close to ceath i came.So please pay attention to your body it will tell you when you are in trouble.I lost the weight i needed to loose to live i had already had heart by pass and i have a ICUD inplanted to keep my heart stable so i am blessed i lost from 318 to 216 and i feel like a new man other than right now i am still recovering from my surgery.So my message is please always pay close attention to the changes in your body it will let you know when you are in trouble.Get checkd out when you feel something had changed soon is never to SOON!!!!!!Good luck to all of you…..

  9. scarlett says:

    I am 3.5 years post-op RYGB. For the past few months I have had several episodes of epigastric pain. I seriously thought I was having a heart attack. My Dr. did a workup but nothing showed up “thank goodness”. He gave me some antispasmodics for when I have the episodes. It helps some but the pain is now more frequent and I am a bit worried. When I have the pain it is hurts right in the middle under my xyphoid process. I sometimes get diaphoretic and a panicky feeling. Does this sound anything like what you guys were feeling. I have had no complications from my surgery at all and have been very pleased losing all of my weight with only approx 20 pound regain.

  10. Jenni says:

    This happened to me! I have my LGBP in 9/09 and have lost 115lbs. I started getting severe stomach pains on 3/4 then went to my regular doctor thinking it had nothing to do with my LGBP and they thought I had something wrong with my gall bladder or my kidneys. I had an ultrsound done where they told me I was “fine”. The continued to get worse…I threw up 20 times one night and was fine the next day. A couple days later I had another episode and work and started throwing up again. I left work and had my husband take me to the ER. I have had three kids and know what pain is, but this was the worst pain I have ever had in my life. I thought I was going to die. They did XRays and CT Scan to find that I had an internal hernia and a bowel obstruction. My LGBP surgeon arrived quickly and performed my emergency surgery. I was literally dying because my body was poisoning itself with waste. They extracted 90 ozs of waste from my intestine. My surgeon said if I would have waited any longer I would have died. Thank God for smart doctors who know what to look for.

  11. aaron says:

    I am calling the doctor tomorrow morning when I get out of work! I have neglected going in on my 6 month and 1 year follow up appointments, and have had some of these problems for a while. My bowel movements are infrequent, as they have been from day 1. But, when I don have them, it is a large amount, and often it is with some abdominal pain, sometimes enough to make my palms sweat. I also have these “episodes” where I get really weak, short of breathe, and I start pouring sweat. I sweat so much that it leaves an outline of me on the sheets. Also, does anyone else have bad gas all the time? I get bad pain often, but I think its an acid issue, as it goes away when I take a prilosec within a few minutes. The “episodes” I mentioned above, I used to think was more of a dumping syndrome at first, but then noticed it happened without any intake of sugar or carbs, then I stumbled across a youtube video about petersons hernia, which led me here. Hopefully someone replies to my post that has had one. It doesn’t hurt after I eat, unless I eat too fast or too much.

  12. Jon says:

    I had my Laparoscopic Gastric Bypass in March 2011. I have since lost 150lbs. Over the last couple of months I had a couple of episodes of severe abdominal pain with extreme dry heave vomitting, which lasted anywhere from 3-12 hours. I thought I was having a “dumping” episode but every time this happened I had finished eating 3-4 hours ago. During the second episode the pain was so intense I went to the ER where a CT scan and blood work was done. Everything came back negative. Two weeks later I had another episode except this time the pain was off the chart. Once again the doctor ordered blood work and this time a HIDA scan to check the gallbladder.Evertyhing looked good after the HIDA scan. I consulted with my surgeon again and mentioned to him that on occasion I would feel a pop or as if a muscle was almost snapping in the area of my stomach. Over the months I had noticed this movement or pop but never paid attention because I thought it was just muscle and things moving around. The other day this popping effect happended several times within a 5 minute span and this area became sore. So I have come to the conclusion after reading this article and viewing all these responses I am convinced I might have a hernia. I am hopeing its nothing but I want to be sure so I am going to have a diagnostic laparoscopy soon. I have no regrets having this surgery. At 37 years old I couldn’t be happier with the weight loss. Dedication and following the nutritionist and surgeon recommendations is key folks.

  13. Michelle says:

    Help! After reading all these I know or believe to the best of my knowledge this is what is wrong with me. How do I get a doctor to believe me? Let me tell my story. I had the Roux en y 6 1/2 years ago. Much longer than any of you but still my symptoms are the same. Sept. 15th 2011 I had pains that I thought were dumping syndrome after attending a funeral and I had only had a diet soda. Which I drink every day. I had it from a fountain and since I wasn’t in my home town I thought it must not have been diet. I was in horrific pain for 11 hours. I had had a hysterictomy 6 weeks earlier so I still had morphine. I took one and nothing. Two hours later one more and still no relief what so ever. No more pains or problems for two weeks. Next time taking my regular meds and 30 minutes later I had severe oh my god I need my mommy pain for 4 hours. Must be dumping again but why now?. Ok drink ice coffee every day. Went to work 2 weeks ago and had a 1/4 cup of my coffee and I had gut wrenching pain that sent me into dry heaves for 3 hours. Came home tried to lay down and the pain was unbearable. Went to em emergency they ran blood test and said nothings wrong go home. I was so mad because damn them I knew something was wrong. I got on here and started typing all my symptons and nothing came up matching everything. I know I have a hernia but since my mom has had 4 I thought it didn’t have anything to do with it. But on a whim decided to see if it was possible for them to become painful. Well omg not only is it possible much more likely with my gastric by pass which my mom didn’t have. The next day I made an appointment at the doctors and asked if I could have a referral to a bariatric doctor since my original doc is 18 hours away and not covered under kaiser my new insurance. Well they said no and to come and be seen if I am still having pain. Well I told the doc my findings and she of course thought I was crazy and not to diagnose myself off the internet. She examined me for a hernia and said I didn’t have one. I was put on medication to stop my heavy periods last year and gained 60lbs and this doc laid me on my back to see If I have a hernia. Well OF COURSE she didn’t find one and becuase I demanded a ct scan she gave me one. Well the scan showed nothing and I had to actually make a formal complaint to get to see the bariatrian and now they don’t have an appoint until Nov 7th. Most of you have had days left when they found your problem. how do I get a doctor to take me seriously? HELP!!!!! Oh yeah forgot to mention have had severe sweats so bad that I almost passed out in Target. Thought it was due to my Hysterectomy and bad gas so bad that my boyfried slept with a shirt covered in lysol over his face and the fan on. I am so embarrassed to admit that. But hey I have to be honest here. Again that that it had something to do with the recent surgery. I am going to the bathroom and there are bowel sounds very loud sounds that sitting near me you can hear not next to me just near. I also can’t eat more than 3 bites of food or liquid at a time and I was able to eat normally just not excessively. I could also down 96 to 120 oz of liquid a day and now I am like to get in 32. Any comments or advice?

  14. cindy says:

    Hello my name is Cindy, I had a gastric September2010, and have lost 115 pounds, since July have ben having tummy pain in my abdomen, would last few hours couple of says and then subside, would take laxative thnking I was constipated,called the nurse she said if this does not settle down in a day or 2 call back, it did continue thien thinking ok its my diveticulous I have minor div. continued after walking, swiming, would be in pain, now its in my back the pain and my left side when I sit, I often break into a sweat and keep thinking its menopause am 51 had a hysterectomy 10 years ago 1 ovary left but theses sweats are incerdible I am soaking wet.Finally called again and went for Ultrasound, and Ct scan results came back, and apparently the nurse says there is something wrong with my small bowel there are clumps, and thinks it could be a internal hernia, was suppose to cal me back to see doctor this week surgeon as he is doing acute care and never heard back nedless to say this was fridayDec16, no call she said I will be in touch friday if not me someone will def. be in touch, no call so I have all weekend long to ponder this neuroticaly as almost lost my hubbiw with the same thing in October, radioligist read his scan wrongly in Vancouver, we flew home immedialty seen surgeon tuesday at 11.00 am and he was in surgery at 1.00pm felt like a million dollars after surgery . Now I am worried sick although its sunday I should hear tommorrow, its christmas week and am not knowing whats going to happen I am totally nervous if this needs out I want it done now not after the holidays anyone out thee can shed some light pleasse do, the nurse says small bowel clusters, eechh, please come monday.

  15. Trish says:

    I had GB about 8 years ago, no complications. 4 years ago i gave birth to my daughter via C section, also no complications. After her birth my stomach has never gone down, it still looks like i’m 9 months pregnant. For the longest time i just thought my body had changed and that i couldn’t lose the weight…….. then i noticed that when I try to sit up my abs go into a triangle shape and i have no muscle strength at all. I believe it is a hernia but i didnt think it was that serious (except for cosmetic) until now that i’m reading this article. Does anyone have any advice on what kind of Dr I should see in order to start the process of getting this taken care of? I’m tired of having a major round belly and scared that it is much more serious than that.

  16. krista k says:

    i am one month post-op. never recovered well. just found out i have a hernia. another surgery. i am worried.

  17. Starr says:

    I also had a LGBP on December of 09. Just before Christmas this year I had extreme pain. I thought I was dying. I went to the ER and through a CT they found an internal hernia. I was transported back to my original GP doctor and he did the surgery right away. I felt a lot better but not a 100%. I final started feeling better and did my followup and the doctor released me to full work outs. So I started working out again.
    Needless to say, I just got release yesterday from the hospital from the internal hernia. The doctor had to back in and add in addition mesh and make some more repairs. The doctor said it’s a result of the weight loss and that I have a void in which my intestines want to go I to that they are not supposed to . Well I hope this is the last time I have to do this surgery.
    Regardless, after this surgery I felt like. 100%. Just a little sore from the surgical marks.
    Everyone that has gastric bypass should be more aware of the fact that internal hernias are very common and what to look for so it can be caught early. I also miscarried during time as well.GBP does wonders and would not change it for the world, but I wish I would have known about this prior.