Anatomical basis for the low incidence of internal hernia after a laparoscopic Roux-en-Y gastric bypass without mesenteric closure.

BACKGROUND: Different techniques have been designed to reduce the rate of internal hernia (IH) after laparoscopic bariatric surgery, and mesenteric closure is possibly the most controversial. We propose a laparoscopic Roux-en-Y gastric bypass (LRYGB) procedure without mesenteric closure with several specific technical details to avoid IH. To support this view, we have reviewed the outcome of our LRYGB patients and have carried out an anatomical study on cadavers.

METHODS: A retrospective observational study was carried out using the Unit's prospective database. The patients selected were those who were operated on for morbid obesity using LRYGB and who presented to the Emergency Unit with symptoms of intestinal obstruction (IO). Data concerning demographics, weight progress, technical details of the surgery, follow-up percentage, morbidity, and mortality were collected. Furthermore, an anatomical model was made in order to recreate the surgery on cadavers.

RESULTS: Only 1.6 % of postoperative IO and very few (0.3 %) of IH cases were associated with our technique of LRYGB without mesenteric closure. The anatomical model showed two large potential hernia spaces, but their supramesocolic situation, the orientation of the bowel loops, leaving the mesentery and omentum undivided and the antecolic passage of the alimentary limb made intestinal herniation difficult even though the mesenteric spaces were not closed.

CONCLUSIONS: With a proper technique, the closure of mesenteric spaces after a LRYGB is not essential to avoid postoperative IH in bariatric patients, as evidenced in an anatomical model.