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Examine weaknesses in the other mesenteric gaps for IH to reduce the risk of recurrence

Updated: Jun 9, 2023

Researcher from Lund University and Skåne University Hospital, Malmö, Sweden, have report that surgery for internal herniation (IH) showed a low risk of recurrence in the treated mesenteric gap but a high risk of recurrence in the other mesenteric gap. They noted that the outcomes stress the importance of carefully investigating weaknesses or gaps in the other mesenteric gap at the time of surgery for IH to reduce the risk of recurrence.

The authors noted that IH is the most common complication after Roux-en-Y gastric bypass surgery (RYGB). Despite primary closure reducing the incidence, recurrences continue to be a problem. Therefore, they instigated a study to investigate long-term follow-up and recurrence risk of IH surgery. This retrospective cohort study included 444 laparoscopic RYGB patients and surgery for incarcerated internal herniation was performed on 44 patients between April 2012 and April 2015 at Skåne University Hospital in Malmö, Sweden.

Status of primary closure of mesenteric gaps, time since RYGB and findings at IH surgery were retrieved from medical records. Patients were followed up until December 2019 and included recurrences of IH, number of computed tomography scans, emergency visits, readmissions and other acute surgeries.

In total, IH (n=44) were identified – both in Petersen’s space (n=24) and beneath the jejunojejunostomy (n=20). About half of the patients had IH despite closed mesenteric gaps at RYGB surgery, clips were the most common primary closure method (18/21). Surgeries for IH were mostly attempted laparoscopically (42/44) but with a high conversion rate of 38%. All open mesenteric gaps were closed using running sutures - non-absorbable sutures were used for 38 patients and absorbable sutures for two patients.

Long-term follow-up of in median of 74.8 months was available for 43/44 (98%) patients treated for acute IH (one patient moved abroad and was lost to follow-up). They reported that six patients (14%) required surgery for recurrent IHs with first recurrences occurring in the other mesenteric gap vs. the first internal hernia, i.e., in Petersen’s space if the first herniation was beneath the jejunojejunostomy and vice versa. One patient had a third IH while another patient suffered four IHs, all occurring in Petersen’s space. Interestingly, none of the five patients operated on by surgeons with bariatric competency had a recurrence of IH.

“The current study showed an internal herniation recurrence risk of 14% over a 6-year follow-up which is lower than previously published data, but still higher than the reported risk of primary IH. About a third of all readmitted patients (6/17) suffered a recurrence of internal herniation, proving the importance of maintaining a high degree of suspicion in readmitted patients,” they noted.

The findings were reported in the paper, ‘Long-Term Follow-up and Risk of Recurrence of Internal Herniation after Roux-en-Y Gastric Bypass’, published in Obesity Surgery. To access this paper, please click here


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