Mechanical ileus and mesenteric ischemia in a patient with simultaneous internal herniation through Petersen's and jejunojejunal spaces following laparoscopic Roux-en-Y gastric bypass: A case report

INTRODUCTION: Internal herniation (IH) of the small bowel after laparoscopic Roux-en-Y gastric bypass (LRYGB) is a well-known complication, with an incidence ranging from 1 to 5% depending on the route of the Roux limb and the closure of the mesenteric defects at the time of the initial operation. Simultaneous herniation of the biliopancreatic and Roux limbs through both Petersen's and jejunojejunal spaces with mesenteric torsion resulting in early small bowel ischemia has not been described earlier. PRESENTATION OF CASE: A 63-year-old patient presented with mechanical small bowel ileus and early mesenteric ischemia due to simultaneous herniation of the alimentary and the biliopancreatic limb through the Petersen's and jejunojejunal spaces with subsequent rotation and torsion of the mesentery 33 months after LRYGB. The condition was managed by surgically reducing the hernias and closure of the mesenteric defects. Partial bowel resection was not performed. The patient's postoperative course was uneventful. DISCUSSION: Simultaneous herniation of the biliopancreatic and Roux limbs through both intermesenteric windows caused consequent life-threatening complications after LRYGB. Antecolic approach and closure of mesenteric defects with non-absorbable sutures are recommended when technically feasible. Proper history taking and clinical examination, as well as communication between surgeons and radiologists, are crucial in establishing a rapid diagnosis. CONCLUSION: Internal hernia following LRYGB can be fatal. In cases of uncertainty, emergency exploratory laparoscopy or laparotomy should be performed. The open approach seems superior for recurrent small bowel obstruction (SBO) due to recurrent IH. High vigilance is necessary when IH is suspected, despite normal laboratory and radiological findings.