Jessica Ardila-Gatas, MD, Linden Karas, MD, Ali Aminian, MD. Cleveland Clinic
Introduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common bariatric procedure performed to date. Complications can develop early or late in the postoperative course. When patients present with symptoms of GI obstruction, the surgeon should have a high suspicion for internal hernia due to its devastating consequences. Other less common causes of obstruction should always be considered. Ventral incisional hernias, port site hernias, hiatal hernias and diaphragmatic hernias have been described.
Case Description: This is a 62 year old female, who underwent a LRYGB 8-years ago with successful weight loss. She complicated with marginal ulcerations which were treated medically and resolved. She presented now with epigastric abdominal pain and nausea. Marginal ulcer was ruled out with upper endoscopy. A computed-tomography scan revealed a new large defect in the anterior diaphragm, omentum and transverse colon were herniated through it. Cholelithiasis was also seen. She was taken to the operating room were a large anterior diaphragmatic hernia was found on the left side of the falciform ligament. The hernia contents were reduced into the abdominal cavity (a long segment of transverse colon and greater omentum). The edge of the hernia sac was grasped and pulled inferiorly and with blunt dissection, the sac was released from the mediastinal adhesions and excised. The hernia defect was repaired primarily using V-lock suture and the Endo-Stitch device. Because the primary repair was under moderate tension, it was reinforced with a piece of Gore Bio-A mesh. The mesh was fixed to the diaphragm and anterior abdominal wall with tacks and glue. Interrupted sutures were placed where the mesh bordered the heart. A standard cholecystectomy was also performed. The patient recovered well and was discharged home on postoperative day 2.
Discussion: Diaphragmatic hernia after LRYGB is a rare complication. Early detection with imaging and surgical repair should be achieved to prevent strangulation of the herniated organs. Laparoscopic repair has been described to be safe and feasible.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85540
Program Number: V267
Presentation Session: Friday Video Loop (Non CME)
Presentation Type: VideoLoop