Journal of Gastrointestinal Surgery

, Volume 18, Issue 2, pp 250–256

Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass

  • Ayman Obeid
  • Sandre McNeal
  • Matthew Breland
  • Richard Stahl
  • Ronald H Clements
  • Jayleen Grams
2013 SSAT Plenary Presentation



The goal of this study was to determine the impact of mesenteric defect closure and Roux limb position on the rate of internal hernia after laparoscopic Roux-en-Y gastric bypass (LRYGB).


A retrospective review was conducted of all LRYGB patients from 2001 to 2011 who had all internal hernia (IH) defects closed (DC) or all defects not closed (DnC).


Of 914 patients, 663 (72.5 %) had DC vs. 251 (27.5 %) with DnC, and 679 (74.3 %) had an ante-colic vs. 235 (25.7 %) with a retro-colic Roux limb. Forty-six patients (5 %) developed a symptomatic IH. Of these, 25 (3.8 %) were in the DC vs. 21 (8.4 %) in the DnC group (p = 0.005), and 26 (3.8 %) were in the ante-colic vs. 20 (8.5 %) in the retro-colic Roux limb position (p = 0.005). Data from 45 patients were available for further analysis. The most common symptom was chronic postprandial abdominal pain (53.4 %). All patients underwent CT scan consistent with IH in 26 patients (57.5 %), suggestive in 7 (15.6 %), showing small bowel obstruction in 4 (8.9 %), and negative in 8 (17.8 %).


Closure of mesenteric defects and ante-colic Roux limb position result in a significantly lower IH rate. Furthermore, a high index of suspicion must be maintained since symptoms may be nonspecific and imaging may be negative in nearly 20 % of patients.


Bariatric surgery Laparoscopic gastric bypass Internal hernia 


  1. 1.
    Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg 1994;4:353–357.PubMedCrossRefGoogle Scholar
  2. 2.
    Nguyen NT, Goldman C, Rosenquist CJ, Arango A, Cole CJ, Lee SJ, Wolfe BM. Laparoscopic versus open gastric bypass: a randomized study of outcomes, quality of life, and costs. Ann Surg 2001;234:279–289.PubMedCrossRefGoogle Scholar
  3. 3.
    Luján JA, Frutos MD, Hernández Q, Liron R, Cuenca JR, Valero G, Parrilla P. Laparoscopic versus open gastric bypass in the treatment of morbid obesity: a randomized prospective study. Ann Surg 2004;239:433–437.PubMedCrossRefGoogle Scholar
  4. 4.
    Smith SC, Edwards CB, Goodman GN, Halversen RC, Simper SC. Open vs. laparoscopic Roux-en-Y gastric bypass: comparison of operative morbidity and mortality. Obes Surg 2004;14:73–76.PubMedCrossRefGoogle Scholar
  5. 5.
    Hutter MM, Randall S, Khuri SF, Henderson WG, Abbott WM, Warshaw AL. Laparoscopic versus open gastric bypass for morbid obesity: a multicenter, prospective, risk-adjusted analysis from the National Surgical Quality Improvement Program. Ann Surg 2006;243:657–666.PubMedCrossRefGoogle Scholar
  6. 6.
    Jones KB Jr, Afram JD, Benotti PN, Capella RF, Cooper CG, Flanagan L, Hendrick S, Howell LM, Jaroch MT, Kole K, Lirio OC, Sapala JA, Schuhknecht MP, Shapiro RP, Sweet WA, Wood MH. Open versus laparoscopic Roux-en-Y gastric bypass: a comparative study of over 25,000 open cases and the major laparoscopic bariatric reported series. Obes Surg 2006;16:721–727.PubMedCrossRefGoogle Scholar
  7. 7.
    Obeid A, Long J, Kakade M, Clements RH, Stahl R, Grams J. Laparoscopic Roux-en-Y gastric bypass: long term clinical outcomes. Surg Endosc 2012;26:3515–3520.PubMedCrossRefGoogle Scholar
  8. 8.
    Blachar A, Federle M, Pealer K, Ikramuddin S, Schauer P. Gastrointestinal complications of laparoscopic Roux-en-Y gastric bypass surgery: clinical and imaging findings. Radiology 2002;223:625–632.PubMedCrossRefGoogle Scholar
  9. 9.
    Podnos YD, Jimenez JC, Wilson SE, Stevens CM, Nguyen NT. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003;138:957–961.PubMedCrossRefGoogle Scholar
  10. 10.
    Nguyen N, Huerta S, Gelfand D, Stevens M, Jeffrey J. Bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2004;14:190–196.PubMedCrossRefGoogle Scholar
  11. 11.
    Husain S, Ahmed A, Johnson J, Boss T, O’Malley W. Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Arch Surg 2007;142:988–993.PubMedCrossRefGoogle Scholar
  12. 12.
    Koppman JS, Li C, Gandas A. Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass: A review of 9,527 patients. J Am Coll Surg 2008;206:571–584.PubMedCrossRefGoogle Scholar
  13. 13.
    Garrard CL, Clements RH, Nanney L, Davidson JM, Richards WO. Adhesion formation is reduced after laparoscopic surgery. Surg Endosc 1999;13:10–13.PubMedCrossRefGoogle Scholar
  14. 14.
    Miyashiro L, Fuller W, Ali M. Favorable internal hernia rate is achieved using retrocolic, retrogastric alimentary limb in laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2010;6:158–164.PubMedCrossRefGoogle Scholar
  15. 15.
    Cho M, Pinto D, Carrodeguas L, Lascano C, Soto F, Whipple O, Simpfendorfer C, Gonzalvo JP, Zundel N, Szomstein S, Rosenthal RJ. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Dis 2006;2:87–91.PubMedCrossRefGoogle Scholar
  16. 16.
    Escalona A, Devaud N, Gustavo P, Crovari F, Boza C, Viviani P, Ibanez L, Guzman S. Antecolic versus retrocolic alimentary limb in laparoscopic Roux-en-Y gastric bypass: a comparative study. Surg Obes Relat Dis 2007;3:423–427.PubMedCrossRefGoogle Scholar
  17. 17.
    Finnell CW, Madan AK, Tichansky DS, Ternovits C, Taddeucci R. Non-closure of defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg 2007;17:145–148.PubMedCrossRefGoogle Scholar
  18. 18.
    Madan A, Lo Menzo E, Dhawan N, Tichansky D. Internal hernia and nonclosure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg 2009;19:549–552.PubMedCrossRefGoogle Scholar
  19. 19.
    Champion JK, Williams M. Small bowel obstruction and internal hernias after laparoscopic Roux-en-Y gastric bypass. Obes Surg 2003;13:596–600.PubMedCrossRefGoogle Scholar
  20. 20.
    Abasbassi M, Pottel H, Deylgat B, Vansteenkiste F, Van Rooy F, Devriendt D, et al. Small bowel obstruction after antecolic antegastric laparoscopic Roux-en-Y gastric bypass without division of small bowel mesentery: a single center, 7 year review. Obes Surg 2011; 21: 1822–1827.PubMedCrossRefGoogle Scholar
  21. 21.
    de la Cruz-Munoz, Cabrera C, Cuesta M, Hartnett S, Rojas R. Closure of mesenteric defect can lead to decrease in internal hernias after Roux-en-Y gastric bypass. Surg Obes Relat Dis 2011; 7: 176–180.Google Scholar
  22. 22.
    Filip JE, Mattar SG, Bowers SP, Smith CD. Internal hernia formation after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Am Surgeon 2002;68:640–643.PubMedGoogle Scholar
  23. 23.
    Iannelli A, Facchiano E, Gugenheim J. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2006;16:1265–1271.PubMedCrossRefGoogle Scholar
  24. 24.
    Bauman RW, Pirrello JR. Internal hernia at Petersen’s space after laparoscopic roux-en-Y gastric bypass: 6.2% incidence without closure – a single surgeon series of 1047 cases. Surg Obes Relat Dis 2009;5:565–570.PubMedCrossRefGoogle Scholar
  25. 25.
    Nandipati K, Lin E, Husain F, Srinivasan J, Sweeney J, Davis S. Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB). J Gastrointest Surg 2012;16:675–681.PubMedCrossRefGoogle Scholar
  26. 26.
    Facchiano E, Iannelli A, Gugenheim J, Msika S. Internal hernias and nonclosure of mesenteric defects during laparoscopic Roux-en-Y gastric bypass. Obes Surg 2010;20:676–678.Google Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2013

Authors and Affiliations

  • Ayman Obeid
    • 2
  • Sandre McNeal
    • 2
  • Matthew Breland
    • 2
  • Richard Stahl
    • 2
  • Ronald H Clements
    • 1
  • Jayleen Grams
    • 2
  1. 1.Department of SurgeryVanderbilt UniversityNashvilleUSA
  2. 2.Department of SurgeryUniversity of Alabama at BirminghamBirminghamUSA

Personalised recommendations