• Case report
• Diagnosis
• Endoscopic retrograde cholangiopancreatography
• Internal hernia
• Treatment

The incidence of internal hernias has recently increased in concordance with the popularization of laparoscopic surgery. Of particular concern are internal hernias occurring in Petersen's space, a space that is surgically created after treatment for gastric cancer and obesity. These hernias cause devastating sequelae, such as massive intestinal necrosis, fatal Roux limb necrosis, and superior mesenteric vein thrombus. In addition, protein-losing enteropathy (PLE) is a rare syndrome involving gastrointestinal protein loss, although its relationship with internal Petersen’s hernias remains unknown.

A 75-year-old man with a history of laparotomy for early gastric cancer developed Petersen's hernia 1 year and 5 mo after surgery. He was successfully treated by reducing the incarcerated small intestine and closure of Petersen’s defect without resection of the small intestine. Approximately 3 mo after his surgery for Petersen’s hernia, he developed bilateral leg edema and hypoalbuminemia. He was diagnosed with PLE with an alpha-1 antitrypsin clearance of 733 mL/24 h. Double-balloon enteroscopy revealed extensive jejunal ulceration as the etiology, and it facilitated minimum bowel resection. Pathological analysis showed extensive jejunal ulceration and collagen hyperplasia with nonspecific inflammation of all layers without lymphangiectasia, lymphoma, or vascular abnormalities. His postoperative course was unremarkable, and his bilateral leg edema and hypoalbuminemia improved after 1 mo. There was no relapse over the 5-year follow-up period.

PLE and extensive jejunal ulceration may occur after Petersen's hernia. Double-balloon enteroscopy helps identify and resect these lesions.

• Internal hernia
• Ulcer
• Protein-losing enteropathy
• Double-balloon enteroscopy
• Ischemia-reperfusion injury
• Case report

• Bariatric surgery
• Complications
• Internal hernia
• Obesity
• One anastomosis gastric bypass

• Gastric Bypass/adverse effects
• Humans
• Internal Hernia
• Laparoscopy
• Obesity, Morbid/surgery
• Retrospective Studies

• Università degli Studi di Roma La Sapienza

• Female
• Gastric Bypass
• Hernia, Abdominal
• Humans
• Obesity, Morbid
• Pregnancy

• obesit
• bariatric surger
• surgical techniqu
• laparoscopic gastric bypas
• petersen’s herni
• obesidad
• cirurgia bariátric
• técnica cirúrgic
• bypass gástrico laparoscópic
• hérnia de petersen

• Duodenum/diagnostic imaging
• Gastric Bypass/adverse effects
• Gastric Bypass/methods
• Hernia, Abdominal/diagnostic imaging
• Hernia, Abdominal/etiology
• Humans
• Jejunum/diagnostic imaging
• Laparoscopy/adverse effects
• Laparoscopy/methods
• Radiography, Thoracic/methods
• Reproducibility of Results
• Surgical Instruments
• Thoracic Vertebrae/diagnostic imaging
• Tomography, X-Ray Computed/methods

• Bariatric surgery
• Gastric bypass
• Herniorrhaphy
• Petersen’s hernia

Robotic assisted pancreaticoduodenectomy (RPD) is reported to be safe and feasible. Internal hernia (IH) after RPD is a serious but rarely reported complication.

We retrospectively reviewed data of 231 patients who underwent RPD from October 2010 to December 2016. The incidence, symptoms, time of presentation, and outcome were investigated.

Five patients (2.6%) were diagnosed with IH. Significant correlation (P<0.001) between IH and transverse mesocolon defect was confirmed. In patients without defect closure, the incidence of IH was 62.5%, while patients who received defect closure experienced no IH. The median time between initial surgery and occurrence of IH was 76 days. The main symptoms were abdominal pain, nausea, and vomiting. All patients received abdominal computed tomography (CT) and were suspected to have IH according to imaging and symptoms. All patients underwent reoperation (2 laparoscopic and 3 open surgery). The median length of hospital stay was 13 days. No patient experienced a relapse after treatment.

Abdominal pain, nausea, and vomiting were common symptoms in our study patients who underwent RPD. IH should be suspected if there is a positive finding on CT. Timely reoperation is necessary because IH may cause intestinal ischemia. Meticulous closure of the mesenteric defect is vital to avoid IH.

: Among Roux-en-Y gastric bypass complications is the occurrence of intestinal obstruction by the appearance of internal hernias, which may occur in Petersen space or the opening in mesenteric enteroenteroanastomosis.

: To evaluate the efficiency and safety in performing a fixing jejunal maneuver in the transverse mesocolon to prevent internal hernia formation in Petersen space.

: Two surgical points between the jejunum and the transverse mesocolon, being 5 cm and 10 cm from duodenojejunal angle are made. In all patients was left Petersen space open and closing the opening of the mesenteric enteroenteroanastomosis.

: Among 52 operated patients, 35 were women (67.3%). The age ranged 18-63 years, mean 39.2 years. BMI ranged from 35 to 56 kg/m² (mean 40.5 kg/m²). Mean follow-up was 15.1 months (12-18 months). The operative time ranged from 68-138 min. There were no intraoperative complications, and there were no major postoperative complications and no reoperations. The hospital stay ranged from 2-3 days. During the follow-up, no one patient developed suspect clinical presentation of internal hernia. Follow-up in nine patients (17.3%) showed asymptomatic cholelithiasis and underwent elective laparoscopic cholecystectomy. During these procedures were verified the Petersen space and jejunal fixation. In all nine, there was no herniation of the jejunum to the right side in Petersen space.

: The fixation of the first part of the jejunum to left side of the transverse mesocolon is safe and effective to prevent internal Petersen hernia in RYGB postoperatively in the short and medium term. It may be interesting alternative to closing the Petersen space.