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Abdominal pain is the most frequent cause of hospital admission after Roux-en-Y gastric bypass (RYGBP). Among the different possible underlying conditions that may cause abdominal pain in bariatric surgery patients, internal hernias represent one of the most peculiar and insidious, as the differential diagnosis is challenging, and the consequences of a delayed treatment may be catastrophic.
The construction of the RYGBP leads to the creation of "artificial" defects in the mesentery when the Roux limb ascends from the inframesocolic compartment to the superior compartment to be anastomosed to the gastric pouch. These mesenteric defects include the jejuno-jejunal mesenteric defect, Petersen’s defect (the potential defect between the alimentary Roux limb and the transverse mesocolon), and mesocolic defect (the opening in the transverse mesocolon when retrocolic gastrojejunostomy is created, which appears only in retrocolic RYGBP reconstructions).
The risk of internal hernias after RYGBP ranges between 2 and 9%. It remains a major concern because they may result in potentially life-threatening small bowel obstruction, ischemia, and necrosis. They can occur at any time during the postoperative period, but they usually appear late with weight loss and the disappearance of perivisceral fat.
The diagnosis of internal hernias is a real challenge: they have a variable clinical presentation and the reliability of diagnostic imaging tests is low. In case of suspicion with a normal CT scan, an urgent diagnostic laparoscopy is mandatory.
Studies show that the strategy of closing all mesenteric defects in a continuous fashion using non-absorbable sutures can lead to a low internal hernia rate <1% and low morbidity from internal hernia after RYGBP.