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Preventing Petersen hernia

Alternative method preventing Petersen post-RYGB

Randomised prospective studies are required to compare the efficiency, surgical time and security between the routine closure of Petersen space and the jejunal fixation manoeuvre

Researchers from Brazil have proposed an alternative to closing the Petersen space and thereby preventing internal Petersen hernia in postoperative Roux-en-Y gastric bypass (RYGB) patients. In their paper, ‘Fixing jejunal maneuver to prevent Petersen hernia in gastric bypass, published in the journal, Arquivos Brasileiros de Cirurgia Digestiva, they conclude that in their experience in 52 patients, fixing the first part of the jejunum on left side of the transverse mesocolon was safe, effective and prevented internal hernia in Petersen space in RYGB patients in the short and medium term.

The researchers from São Domingos Hospital, Uniceuma, São Luis, MA, the Federal University of Pernambuco, Recife, PE and the Gastro-Obese-Center, São Paulo, SP, Brazil, begin by stating that despite popularity of RYGB) procedure is associated with internal hernias in Petersen space or in the mesenteric opening of enteroenteroanastomosis. The more challenging is the Peterson space that, according to the researchers, can be technically very difficult in some patients (superobese and patients with a severe grade of visceral obesity) and is associated with complications such as bleeding, vascular lesions and hematomas. Whether to close the Peterson space is still hotly debated at bariatric and metabolic meeting around the world, although most studies show that there is a reduction in the incidence of internal hernia when these spaces are closed during the course of RYGB.

The researchers suggest that an attachment suture from the beginning of the jejunum on the left space side can prevent bowel migration to the right side, avoiding the formation of internal hernia, even keeping Petersen space opened. They add that such a solution would be a quick and easy to perform alternative to the routine closure of the space. Therefore, they decided to evaluate the efficiency and safety in performing a jejunal fixation in the transverse mesocolon to prevent internal hernia formation within Petersen space after RYGB.

Study

The recruited 52 patients between January and July 2014 at São Domingos Hospital, who underwent to laparoscopic RYGB with antecolic reconstruction, and during the procedure they performed their new technical proposal to fix the jejunum segment on the left side of the transverse mesocolon.

They explained that when measuring the length of the biliopancreatic limb, the transverse mesocolon was moved cranially to identify the duodenojejunal angle. At this time, before measuring the biliopancreatic limb, patients underwent surgical procedure for fixing the beginning of the jejunum in the transverse mesocolon, with deep suture (in an attempt to lessen the chance of undoing the fixation) on the left side of the mesocolon.

A first, the fixation was performed with only one stitch with a non-absorbable wire between the jejunum (10 cm from duodenojejunal angle) and the transverse mesocolon. However, they have subsequently changed the procedure by passing two stitchs between the jejunum and the transverse mesocolon, being 5cm and 10cm from the duodenojejunal angle. This was aimed at avoiding the space created between this angle and the 10cm position stitch and to reforce the attachment with a second stitch, lessening the chance it could undo the fixation (Figure 1). In all patients Petersen space was left open and the mesenteric opening of the enteroenteroanastomosis was closed.

Figure 1: Technical moments of jejunum fixation to the mesocolon

During routine assessments (one, three, six, 12 and 18 months after surgery) patients were if they presented significant abdominal pain, postprandial pain, vomiting or abdominal distension.

Outcomes

Among 52 patients operated, 35 were women (67.3%). The age ranged 18-63 years, mean 39.2 years. BMI ranged from 35-56 (mean 40.5). Mean follow-up was 15.1 months (12-18 months). The operative time ranged from 68-138 min, with a mean of 89min. There were no intraoperative complications, and there were no major postoperative complications or reoperations. The hospital stay ranged from 2-3 days (50 patients remained in the hospital for two days).

During the evaluations, no patients reported the occurrence of abdominal pain, postprandial pain, vomiting or abdominal distension, and no patients presented suspect clinical presentation of internal hernia during this follow-up.

In the same follow-up period, nine patients (17.3%) presented asymptomatic cholelithiasis (small gallstones) and were submitted to elective laparoscopic cholecystectomy. In all nine patients, there was no herniation of the jejunum to the right side Petersen space. Attempts were made to pull the jejunum (biliopancreatic limb) to the right side of the Petersen space; however, the displacement of the intestine was not possible because the jejunum was fixed to the left side of the mesocolon, showing that the fixation was working (Figure 2).

Figure 2: Late follow-up aspect of the limb attached to the mesocolon

“In the present study, there was no case of internal hernia, suggesting proper efficiency of the fixation manoeuvre, although with no long follow-up as in other publications,” the authors note. “…the fixation was made quickly and with technical ease in all patients, even in superobese and in patients with severe grade of visceral fat, conditions that hinder the proper closure of Petersen space.”

They also report that another possible advantage of the fixing manoeuvre in relation to the closure of Petersen space is related to the case of failures consequences. In their opinion, there would be “no serious consequences in the event of the attachment stitches disengage from the mesocolon, while the inadequate closure of the Petersen space, or its partial opening, appear to be associated with more severe herniation, most likely to ischaemia and intestinal necrosis due to reduced space to be in.”

Despite the promise of the technique, they acknowledge that more studies with larger numbers of patients and longer follow-up are needed to prove the effectiveness in preventing internal hernia in the long term. In particular, they state that randomised prospective studies are required to compare the efficiency, surgical time and security between the routine closure of Petersen space and the jejunal fixation manoeuvre.

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