Laparoscopic Internal Hernia Repair and Closure of Peterson's Defect due to Small Bowel Obstruction

Laparoscopic Internal Hernia Repair and Closure of Peterson's Defect due to Small Bowel Obstruction (SBO)

Angela Echeverria, MD, Bianca Zangeneh, MD, Ulises Garza, MD, Amit Kaul, MD, Carlos Galvani, MD

University of Arizona, Tucson, AZ

Introduction: The incidence of internal hernia is about 0.5% to 9% after a laparoscopic Roux en Y gastric bypass (LRYGB). Peterson's defect is the most common internal hernia from the three types of mesenteric openings. The most sensitive sign to diagnose is a CT scan showing a whirl sign/mesenteric sign (mesenteric vessel rotation). This condition if not diagnosed early can be life threatening.

Methods: This is a 29-year-old female with a one-year history of a laparoscopic surgical Roux en Y gastric bypass with 100 lb of excessive weight loss. The patient came to the ER department with complains of severe epigastric abdominal pain 10/10, nausea and vomit for more than 12 hours. CT showed mesenteric edema, swirling of the central mesentery. The patient was scheduled for diagnostic laparoscopy. The small bowel was twisted and incarcerated in the mesenteric defect of the J-J anastomosis and reduced completely. An opening of the mesenteric J-J anastomosis and the peterson's defect were identified and closed using non-absorbable suture in a running fashion.

Results: Operative time was 55 minutes The patient was discharged 36 hours after surgery. No intraoperative or postoperative complications were seen. The three-month-follow-up was unremarkable.

Conclusion: Patients that undergo LRYGB for morbid obesity are at risk for the development of internal hernias and SBO, general awareness of this condition and high clinical suspicion allow for prompt surgical intervention with decreased morbidity and mortality. Therefore, the best preventative measure is the proper closure of these defects at the time of the initial procedure.