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Internal hernias

Close mesenteric defects during LRYGB to prevent internal hernia

The most frequent site of IH, Petersen’s space, was identified in 80 patients in the non-closure group and 26 in the closure group

Internal hernia (IH) after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a frequent occurrence if mesenteric defects are left unclosed, therefore primary closure with a hernia-stapling significantly reduces the risk of internal hernia, according to a study by researchers from Aleris Hospital, Oslo, Norway.

The study, ‘The mesenteric defects in laparoscopic Roux-en-Y gastric bypass: 5 years follow-up of non-closure versus closure using the stapler technique’, published in the journal Surgical Endoscopy, notes that IH is a major cause of late complications with a reported incidence of 0.5–11% and is thought to be higher in patients undergoing a laparoscopic versus an open approach.

In 2010, the authors report that a new method of closing the mesenteric defects was introduced using a stapler device (Endo Universal 4.8 mm stapler, Autosuture, Medtronic) and this method has been implemented throughout Scandinavia and in other European countries. Therefore, the authors report their five-year experience using this method and whether it is safe and effective in reducing the incidences of IHs.

All consecutive LRYGBs performed between 2005 and November 2015 were included in the study, totalling 1,570 LRYGBs without closure of the mesenteric defects. From June 2010 to November 2015, 2,443 LRYGBs were performed with the mesenteric defects closed. They note there were no significant differences between the groups reagrading demographic data

The closing procedure begins after division of the omega loop and of the mesentery close to the gastroenterostomy. This division is carried down to the edge of the transverse colon, about 5cm down including the marginal vessels. Thus, the enteroenterostomy (EE) will be lying mobile below the transverse colon. The stapler (Endo Universal) is inserted via a 12mm port in the left upper abdomen. Graspers are used to expose the subcolic space behind the alimentary arm (Petersen’s defect) by lifting the transverse colon (Figure 1A).

The staples are partially extended presenting “hooks” that facilitate the catching and adaptation of the mesenteric peritoneum. Great care was taken to avoid deep bites in order to avoid damage to mesenteric vessels. The Petersen’s defect was closed from the root of the mesentery of the Roux limb and transverse mesocolon up to the transverse colon itself. To close the jejunal mesenteric defect, the assistant grasps the end of the duodenal limb and lifts the EE thereby exposing the mesenteric defect behind the EE (Figure 1B). The same port and stapler are used for the closing of this defect.

Figure 1A and 1B: A) Closure of Petersen’s space B) Closure of jejunal mesenteric defect


The outcomes showed that the median hospital stay was two days (range 2–10). With a median follow-up of 77 months (0–121), 270 patients (17.2%) in the non-closure group developed a symptom of IH, requiring surgical intervention. Maximum follow-up in the closure group was 66 months, and in the non-closure group 121 months. When analysing data at 60-month FU time with a Kaplan–Meier estimate, the incidence of confirmed postoperative IH was significantly lower, 2.5% in the closure group compared to 11.7% in the non-closure group (Figure 2).

Survival function diagram using the Kaplan–Meier method demonstrating the relation of IH occurrence to post-operative time. The analysis is based on 4013 patients operated from 2005 to November 2015; number of patients at risk given at top. Green Closed mesenterial openings at index operation. Blue No closure of mesenterial openings at index operation. Solid lines Hernia containing bowel. Dashed lines Suspected hernia without bowel in mesenterial opening at laparoscopic exploration. Longer follow-up in the non-closure group as it preceded the closure group still allows a comparison at 5 years/p>

The hernia-free survival function diagram (Figure 2) illustrates how the IH cases in the non-closure group start to occur at about two months post-operatively and then seem to be uniformly distributed through the first six years. For comparison, the vast majority of the IH’s in the closure group (green lines) occurred within three years. No IH was registered in the closure group after >52 months, with 665 patients remaining at risk.

The most frequent site of IH, Petersen’s space, was identified in 80 patients in the non-closure group and 26 in the closure group.

 “We found that our novel method of closure with the stapler resulted in an IH-rate of 2.5% (60/2444) over five years. This is in contrast to our observed five-year rate of 11.7% for patients left with the mesenterial openings intact.

The authors said that this method is technically unchallenging and expeditious, with only four minutes added to total operating time, and it can be applied in all patients without affecting the complication rate

“Our experience is in line with increasing evidence from several centres that the mesenteric defects should be closed primarily,” the authors conclude. “Our method of primary closure with Endohernia stapling is safe and results in a significantly reduced risk of internal hernia. Regardless of whether the mesenteric defects in LRYGB were primarily closed, suspicion of IH in patients with acute or chronic abdominal pain is still mandatory.”

The article was edited from the original article, under the Creative Commons license

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