Internal Hernia Following Laparoscopic Roux-en-Y Gastric Bypass: Prevention and Tips for Intra-operative Management.

Background: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is considered the golden standard for bariatric surgery. However, the potential risk for internal hernia after LRYGB remains a significant concern to both patients and surgeons. In addition, patients presenting with abdominal pain after LRYGB warrant careful attention to avoid missing or delaying the diagnosis of internal hernia. The aim of this study was to describe our technique to prevent internal hernia after LRYGB, intra-operative findings, and our management strategies for patients with internal hernia after LRYGB.

Methods: In this video, we review different technical tips and tricks to explore patients with suspected internal hernia after RYGB, how to reduce obstructed small bowel, and effectively close mesenteric defects to prevent internal hernia after LRYGB.

Results: A high index of suspicion and evaluation of the CT scan of the patient by an experienced bariatric surgeon is essential to avoid missing cases of internal hernia after LRYGB. In addition, patients presenting with incarcerated small bowel due to an internal hernia are best managed by standing on the left side of the patient with the left arm tucked and starting at the ileocecal valve and running the small bowel backwards towards the ligament of Treitz. Furthermore, patients with bowel obstruction due to internal hernia may need to have a gastrostomy placed at the remnant of the stomach.

Conclusion: Recurrent abdominal pain is not uncommon after LRYGB. Systematic closure of mesenteric defects, the use of diagnostic laparoscopy, and high index of suspicion are all necessary to avoid delay in diagnosis.