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A 51 year-old female with a previous history of autoimmune myositis (treated with 5 mg / day of prednisone), a laparoscopic cholecystectomy and a laparoscopic RYGBP due to morbid obesity (10 years ago with an initial BMI of 44 Kg/m2 and correct weight loss, going from 123Kg to 69Kg). She came to the emergency room due to sudden abdominal pain and persistent nausea. In evaluation her vital signs were stable, but the abdomen was slightly distended with pain at the epigastrium.
White blood cells, PRC and hemostasis parameters were normal. Amylase and lipase were high with normal bilirubin. An abdominal CT Scan was performed to achieve the diagnosis identifying a 6-10 cm segment of proximal jejunum forming a concentric rings image which led to the diagnosis of jejuno-jejunal intussusception.
This intussusception was causing a small bowel occlusion of the biliopancreatic limb as the gut had a diameter of up to 5 cm and a distended gastric remnant.
Emergency surgical revision was performed laparoscopically with the patient under general anesthesia and in the anatomical position.
Pneumoperitoneum was performed with a Veress needle at the upper left abdominal quadrant. A total of three ports were placed, in a configuration similar to that used in the inframesocolic phase of the gastric bypass.
A 12 mm trocar was placed at the right flank for a 30º scope, an 11mm trocar was placed at the umbilicus and a 5mm port was placed at the epigastrium. The leading surgeon stood at the right of the patient with the assistant to his right.
A segment of major omentum was attached to the abdominal wall. The hook was used to release it as it could be a future cause of small bowel occlusion. Notice the distended and viable small bowel, which seems to be the JJ anastomosis.
There was some major omentum also attached to the descending colon. This adhesion was also released as it could become a cause of internal hernia. Special care must be taken if you use the hook as the colon may be close, so try to identify avascular planes. Performing good traction is crucial.
Small bowel revision was performed from the terminal ileum to the proximal jejunum. This strategy allows systematic evaluation of the gut and makes it possible to manipulate the distended bowel last, avoiding injuries. We used laparoscopic Debakey's as they enable good, delicate traction to perform this kind of manipulation.
It should be borne in mind that we are revising a RYGBP so this will be the common channel. As we are revising towards the proximal jejunum, the next thing that must be found is the JJ anastomosis. The best strategy is to try and place all the structures in their original location, and have a well exposed mesentery, evaluating for gaps and hernias. This allows us to identify a big mesentery gap without herniation at the moment.
As the radiological findings suggested that intussusception was located at the level of the biliopancreatic limb, we revise it from the JJ anastomosis to the angle of Treitz . The leading surgeon keeps the biliopancreatic limb in position with his left hand, mobilizing the mesenteric root with his other hand.This maneuver clarifies the situation as the inferior mesenteric vein is identified.
Performing simultaneous traction of the transverse colon and the small bowel makes it possible to identify the Angle of Treitz and the last segment of the duodenum. A final revision of the biliopancreatic limb was carried out. No intussusception was found. The intestinal walls and the mesenterium were in normal position. Maybe this clinical situation arose due to a distended biliopancreatic limb secondary to an intermittent occlusion due to herniations at the level of the mesenteric gap.
The alimentary limb was also revised from the JJ to the gastro-jejunal anastomosis. Notice that we grasped the entire wall of the gut to perform effective traction and avoid injuries. This gut segment was normal. Petersen’s defect was also assessed and found to be sealed.
As a last step in the procedure, the mesenteric gap was closed with a running 2-0 prolene suture. Care was taken to avoid major vascular injuries. This is feasible due to left hand traction.
We are aware that the remnant stomach was distended but as the passage to the common limb was good and there were no signs of perforation, a decompressive gastrostomy was not performed. With this knot we finished the surgical procedure.
Surgery took 84 minutes with no conversion to open approach or intra operative complications. Oral intake started on the second postoperative day and the patient left hospital three days after surgery.
Three months later she remains asymptomatic.
