Internal herniation (IH) through the mesenteric defects is a well- known problem after gastric bypass. Most commonly is the biliopancreatic limb herniating through Peterson space from left to right direction. A less common herniation of alimentary limb and common channel favor right to left direction and can be confusing. We would like to share our experience of a patient with last-mentioned type of herniation.
69 years old female underwent gastric bypass 2009. Since 2016, the patient has experienced problem with heartburn, abdominal pain and vomiting.EGD study was normal. Esophageal manometry and 24-hour pH monitoring was normal. Barium swallow showed Hiatal hernia and short stagnation of barium above the gastroesophageal junction. A decision was made to proceed with laparoscopy.
At laparoscopy, a large hiatal hernia was found. A rotation of the intestine at the gastrojejunostomy and intestinal mesentery at the enteroenterostomy was observed. A single intestinal loop was herniating through Peterson space. We failed to follow the biliopancreatic limb, common channel and the ileum backward from the cecum because the limbs disappear at some point behind the remaining small intestine. The situation was confusing, and it took a while to realize that most of small intestine was herniating through Peterson space from right to left. The herniated intestine was reduced, and the defects was sutured. Patients symptoms resolved after surgery.
The unusual direction of herniation after gastric bypass can be difficult to interpret especially in acute situation. Surgeon awareness of this variation facilitate solving the problem.