Skip to main content
SpringerLink
Log in

Counterclockwise Rotation of Roux-En-Y Limb Significantly Reduces Internal Herniation in Laparoscopic Roux-En-Y Gastric Bypass (LRYGB)

  • 2011 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Introduction

Internal hernias continue to be a significant source of morbidity after LRYGB. Literature addressing the technique of Roux limb construction as a predisposing factor is sparse. The objective of this study is to evaluate the impact of Roux limb construction technique on the development of internal hernias.

Methods

In this study, we included 444 (367 (82.7%) were females and 77 (17.3%) were males, two deaths excluded from the analysis) consecutive patients from our institutional bariatric database who underwent LRYGB. Variables collected include demographics, body mass index (BMI) before and after the procedure, and postoperative small bowel obstruction secondary to internal herniation. Technical details collected include: type of Roux-en-Y limb construction, Peterson’s defect closure at initial operation, and reoperative findings. Roux limbs were constructed in 291 patients by a clockwise rotation of the bowel and jejunojejunostomy performed on the right side of the axis of the mesentery (group 1). In 151 patients, the Roux limb was constructed by a counterclockwise rotation of the Roux limb resulting in the jejunojejunostomy on the left side of the axis of the mesentery (group 2). We also analyzed the impact of Peterson’s space closure on internal hernias. Fisher’s exact test and Chi-square test were used for the analysis.

Results

Of a total 442 (mean age, 43.7 ± 10.3 years; mean BMI pre-op was 46.4 ± 5.1; and BMI after median follow-up of 12 months was 34.5 ± 6.98) patients included in the study, 21 (4.7%) internal hernias were identified. Of 21 internal hernias, 17 (81%) were through Peterson’s space and four (19%) were through the mesenteric defect. Group 1 patients had significantly higher overall internal hernias (20/291, 6.9% vs. 1/151, 0.7%; P = 0.0018) and Peterson’s hernias (16/291, 5.5% vs. 1/151, 0.7%; P = 0.0089) compared with group 2. In addition, no significant difference was noted in the incidence of Peterson’s hernia whether the defect was closed or not closed (closed group, 4/117 and 3.4% vs. not closed, 13/325, 4%; P = 1.00). Within the group where Peterson’s defect was closed, clockwise rotation and anastomosis on the right side of the axis of the mesentery was associated with significantly higher incidence of Peterson’s hernias compared with counterclockwise rotation (4/54 vs. 0/63; P = 0.043). In the group where Peterson’s defect was not closed, clockwise rotation was associated with higher incidence of internal hernias that did not reach statistical significance (12/237, 5.1% vs. 1/88, 1.1%; P = 0.12).

Summary

This study demonstrates that the technique for construction of the Roux limb is a major factor in the development of internal hernias. Construction of the Roux limb with a counterclockwise rotation of the bowel, such that both jejunojejunostomy anastomosis and ligament of Treitz are to the left of the axis of the mesentery significantly reduces the incidence of internal hernias.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Higa, K. D., K. B. Boone and T. Ho. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients--what have we learned? Obes Surg 2000; 10: 509–513.

    Article  PubMed  CAS  Google Scholar 

  2. Nguyen, N. T., S. E. Wilson and B. M. Wolfe. Rationale for laparoscopic gastric bypass. J Am Coll Surg 2005; 200: 621–629.

    Article  PubMed  Google Scholar 

  3. Varela, J. E., S. E. Wilson and N. T. Nguyen. Laparoscopic surgery significantly reduces surgical-site infections compared with open surgery. Surg Endosc 2010; 24: 270–276.

    Article  PubMed  Google Scholar 

  4. Higa, K., T. Ho, F. Tercero, T. Yunus and K. B. Boone. Laparoscopic Roux-en-Y gastric bypass: 10-year follow-up. Surg Obes Relat Dis 2011; 7(4):516–525

    Article  PubMed  Google Scholar 

  5. Koppman, J. S., C. Li and A. Gandsas. Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass: a review of 9,527 patients. J Am Coll Surg 2008; 206: 571–584.

    Article  PubMed  Google Scholar 

  6. Higa, K. D., T. Ho and K. B. Boone. Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. Obes Surg 2003; 13: 350–354.

    Article  PubMed  Google Scholar 

  7. Quebbemann, B. B. and R. M. Dallal. The orientation of the antecolic Roux limb markedly affects the incidence of internal hernias after laparoscopic gastric bypass. Obes Surg 2005; 15: 766–770; discussion 770.

    Google Scholar 

  8. Bertucci, W., J. Yadegar, A. Takahashi, A. Alzahrani, D. Frickel, K. Tobin, K. Kapur, B. Namdari, E. Dutson, C. Gracia and A. Mehran. Antecolic laparoscopic Roux-en-Y gastric bypass is not associated with higher complication rates. Am Surg 2005; 71: 735–737.

    PubMed  Google Scholar 

  9. Rodriguez, A., M. Mosti, M. Sierra, R. Perez-Johnson, S. Flores, G. Dominguez, H. Sanchez, A. Zarco, K. Romay and M. F. Herrera. Small bowel obstruction after antecolic and antegastric laparoscopic Roux-en-Y gastric bypass: could the incidence be reduced? Obes Surg 2010; 20: 1380–1384.

    Article  PubMed  Google Scholar 

  10. Steele, K. E., G. P. Prokopowicz, T. Magnuson, A. Lidor and M. Schweitzer. Laparoscopic antecolic Roux-en-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach. Surg Endosc 2008; 22: 2056–2061.

    Article  PubMed  CAS  Google Scholar 

  11. Pomp, A. 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: 579.

    Article  PubMed  Google Scholar 

  12. Paroz, A., J. M. Calmes, V. Giusti and M. Suter. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: a continuous challenge in bariatric surgery. Obes Surg 2006; 16: 1482–1487.

    Article  PubMed  CAS  Google Scholar 

  13. Cho, M., D. Pinto, L. Carrodeguas, C. Lascano, F. Soto, O. Whipple, C. Simpfendorfer, J. P. Gonzalvo, N. Zundel, S. Szomstein and R. J. Rosenthal. 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.

    Article  PubMed  Google Scholar 

  14. Hope, W. W., R. F. Sing, A. Y. Chen, A. E. Lincourt, K. S. Gersin, T. S. Kuwada and B. T. Heniford. Failure of mesenteric defect closure after Roux-en-Y gastric bypass. JSLS 2010; 14: 213–216.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, Emory University, 1364 Clifton Rd, H-124, Atlanta, GA, 30322, USA

    Kalyana C. Nandipati, Edward Lin, Farah Husain, Jahnavi Srinivasan, John F. Sweeney & S. Scott Davis

Authors
  1. Kalyana C. Nandipati
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Edward Lin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Farah Husain
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jahnavi Srinivasan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. John F. Sweeney
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. S. Scott Davis
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to S. Scott Davis.

Additional information

Discussant

Dr. Raul J. Rosenthal (Weston, FL): I congratulate the authors for this study addressing an important subject in bariatric surgery such as prevention of internal herniation (IH) after gastric bypass. The literature reports a low incidence of this complication. However, the consequences of IH if not recognized and treated in a timely fashion are devastating. Small bowel obstruction, strangulation, ischemia, short gut syndrome requiring reversal of gastric bypass, or small bowel transplantation are some of the most feared adverse events.

Suture closure of mesenteric defects has been advocated by many authors as means to prevent IH from happening. However in their reports, IH are still present.1

Factors that might influence IH after gastric bypass are: division of the mesentery, length and routing of the Roux Limb in an ante or retro- colic fashion and as newly suggested by the authors, the clock or counterclockwise rotation of the enteroentero anastomosis.2

The authors conclude in this study that

1. At 12 months follow-up, the incidence of IH is 4.7 %.

2. That the counterclock way of the enteroentero anastomosis results in less internal hernias than the clockwise fashion. My comments, questions, and concerns to the above-mentioned conclusions are that the incidence of hernias in the counterclockwise group might be low because of short follow up.

Closing Discussant

Dr. Kalyana Nandipati: We appreciate SSAT and Dr. Rosenthal for reviewing our study and also providing with valuable comments and suggestions. We were able to include most of the suggestions from the reviewer before submitting the final manuscript.

1. The 12 months incidence of early IH seems to be high when compared with most published series. Since IH seem to become clinically apparent at a later time, I recommend a longer follow-up to support or dispute the conclusions of the study. Can the author comment on this observation? What triggered the authors to perform laparoscopy at one year?

Ans: We agree with the reviewer’s comments that our 12-month internal herniation was high (4.8%). We believe that the technique of Roux limb construction was the most important reason for the high incidence of internal hernias in this particular cohort. This probably the main reason also why most our hernias were early in the follow-up. We changed our technique after this study was initiated. We will continue to follow-up on our database to see whether this change of technique reduced the incidence of internal herniation.

2. The authors should also clarify which technique was utilized in this patient cohort, (1) was the Roux limb route in an ante or retro colic fashion? (2) Was the mesentery divided? (3) What was the length of the limbs?

Ans: During this study period Roux limb was constructed only in antecolic fashion. Mesentery was divided in all patients. That is the reason why we also performed a subgroup analysis to see whether the closure of mesenteric defects has any impact on development of internal hernias. Roux limb length was standard in all patients.

3. Finally, my concerns are if the counterclockwise rotation of the enteroentero anastomosis can result in a higher incidence of small bowel obstruction?

Ans: The incidence of internal hernias after counterclockwise rotation was <1%. Which remained same since the study was performed. Our follow-up now has increased to more than 1 year but our rate internal herniation still remains low. We believe that most of the studies published in the literature didn’t provide details about the Roux limb construction. In our opinion, in the future studies reporting internal hernias should have technical details also as a part of evaluation along with other details like weight, closure of defects, length of limb, and type of Roux limb placement. Homogeneity in reporting will allow future studies to identify factors associated with the development of internal herniation.

I thank SSAT for giving me the privilege to comment on this study.

References:

1. Higa KD, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: incidence, treatment and prevention. Obes Surg 2003; 13(3):350-4

2. 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

Min young Cho, M.D., David Pinto, M.D., Lester Carrodeguas, M.D., Surgery for Obesity and Related Diseases 2006; 2 (2): 87–91.

This paper was presented at the 52nd annual meeting of The Society for Surgery of Alimentary Tract, Chicago, IL, 8 May 2011.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Nandipati, K.C., Lin, E., Husain, F. et al. Counterclockwise Rotation of Roux-En-Y Limb Significantly Reduces Internal Herniation in Laparoscopic Roux-En-Y Gastric Bypass (LRYGB). J Gastrointest Surg 16, 675–681 (2012). https://doi.org/10.1007/s11605-011-1755-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-011-1755-8

Keywords

Search

Navigation