|Year : 2022 | Volume
| Issue : 3 | Page : 164-167
Internal hernia in pregnancy after Roux-en-Y gastric bypass: A surgical diagnostic dilemma
Hadiel A Kaiyasah1, Maryam Al Ali2, Laila Alhubaishi3, Shiney Oliver3, Faiza Badawi3, Ali Al Ani1
1 Department of General Surgery, Rashid Hospital, Dubai, United Arab Emirates
2 Emergency Department, Rashid Hospital Trauma Center, Dubai, United Arab Emirates
3 Department of Obstetrics and Gynecology, Latifa Hospital, Dubai, United Arab Emirates
|Date of Submission||19-Nov-2021|
|Date of Decision||14-Apr-2022|
|Date of Acceptance||19-Apr-2022|
|Date of Web Publication||21-Sep-2022|
Hadiel A Kaiyasah
Department of General Surgery, Rashid Hospital, 315 Umm Hurair Second, PO Box 4545, Dubai
United Arab Emirates
Source of Support: None, Conflict of Interest: None
Rationale: Internal hernia after Roux-en-Y gastric bypass (RYGB) is a lifelong risk. During pregnancy, this risk increases due to the rise in the intra-abdominal pressure. Early recognition and intervention are the keys to have a better outcome. The aim of this case report is to shed the light on the possibility of such occurrence. Patient Concerns: A 40-year-old woman presented to the emergency department at 36 weeks of gestation with acute abdominal pain. Diagnosis: She was in labor. In view of her past history of gastric bypass, a surgical consult was obtained. Patient developed episodes of hypotension with deceleration, so an emergency caesarean section was performed. Interventions: The abdomen was explored Intraoperatively. An internal hernia with small bowel volvulus was found. Outcomes: The hernia reduced and bowel revived. Postoperatively, the patient had a smooth recovery and a healthy baby. Lessons: Nowadays, due to the global obesity epidemic, lots of women of childbearing age are undergoing bariatric surgery all over the world. Having the knowledge about the possible complications of such procedures is of paramount importance. This is in order to be able to have an earlier operative intervention whenever indicated, hence, decreasing the maternofetal morbidity and mortality. Internal herniation after RYGB exemplifies a rare, high-risk complication that might occur in pregnancy. A high index of suspicion is required for early diagnosis and better outcome.
Keywords: Acute abdomen, bariatric, gastric bypass, internal hernia, labour, pregnancy
|How to cite this article:|
Kaiyasah HA, Al Ali M, Alhubaishi L, Oliver S, Badawi F, Al Ani A. Internal hernia in pregnancy after Roux-en-Y gastric bypass: A surgical diagnostic dilemma. Hamdan Med J 2022;15:164-7
|How to cite this URL:|
Kaiyasah HA, Al Ali M, Alhubaishi L, Oliver S, Badawi F, Al Ani A. Internal hernia in pregnancy after Roux-en-Y gastric bypass: A surgical diagnostic dilemma. Hamdan Med J [serial online] 2022 [cited 2022 Oct 7];15:164-7. Available from: http://www.hamdanjournal.org/text.asp?2022/15/3/164/356434
| Introduction|| |
As the burden of obesity is growing globally, the percentage of bariatric surgeries performed across the world is significantly rising. In view of that, comprehensive knowledge of the possible complications after such operations is of paramount importance.
Laparoscopic Roux-en-Y gastric bypass (RYGB) is considered among the most commonly performed procedures for the treatment of morbid obesity. While weight loss is the main advantage of bariatric surgery, other positive results include improved fertility in women. This in return can increase the chances of conception.
The risk of internal hernia (IH) after RYGB can rise from the associated increased intra-abdominal pressure during pregnancy. A developing foetus and the physiologic changes of pregnancy can mask the diagnosis and delay intervention, leading to serious maternofoetal consequences.,,
This case report of IH during pregnancy in a patient with a history of RYGB highlights the importance of keeping a high index of suspicion for such diagnosis to have early bariatric consultation and intervention. Thus, preventing life-threatening consequences for both mother and the developing foetus.
| Case Report|| |
A 40-year-old gravida 7, para 6 woman presented to the accident and emergency department at 36 weeks of gestation with a complaint of abdominal pain of 3 h duration. The pain was in the epigastric region and was described as constant and severe in nature. It was not relieved with regular analgesics, associated with nausea and inability to eat. The patient denied any vaginal bleed or leak, trauma, fever, urinary or bowel complaints.
Her blood investigations revealed a white blood cell count of 14 × 109/L, C-reactive protein – 96 mg/L and haemoglobin – 9.4 g/dL. The rest of the laboratories were within the normal limits. On initial assessment, she looked in pain. Her vital signs were within the normal limits. Chest and cardiac examinations were unremarkable. Her abdomen was soft apart from occasional uterine contractions. Bowel sounds were sluggish. A focused ultrasound examination was done and confirmed a single viable foetus with cephalic presentation and placenta lying anteriorly. Vaginal examination revealed a dilated cervix of 3 cm with intact membranes. In view of being in labour, the patient was shifted to another hospital with obstetric service.
At the labour suite, the pain was constantly increasing and not going with the uterine contractions. A dilated bowel loop of 5 cm in diameter was seen on scanning the upper abdomen [Figure 1]. An urgent surgical consult was obtained given the history of laparoscopic of the past history of laparoscopic RYGB surgery done 18 months ago. On reassessment, the patient's blood pressure dropped to 88/50 mmHg along with recorded deceleration on cardiotocography. The decision was to perform an emergency caesarean section through a lower midline laparotomy. A healthy baby boy was delivered.
|Figure 1: Ultrasound abdomen showing dilated bowel loop in the epigastric region|
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Intraoperatively, the surgeon on call attended and explored the whole abdomen after extending the laparotomy incision. An IH was found with a dusky loop of biliopancreatic limb going through a previously sutured Petersen's space. After releasing the concentric ring and reducing the hernia, the colour of the small bowel loop gradually recovered with 100% oxygenation and warm saline packs. Hence, there was no need for bowel resection [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. After identifying the anatomy of the RYGB, the mesenteric defect was left wide open to prevent future internal herniation. The drain was placed in the pelvis, and the laparotomy wound closed in layers.
|Figure 2: Intraoperative findings. (a) Small bowel volvulus due to internal herniation, (b) Mesenteric defect after releasing the fibrotic ring and reduction of hernia, (c) jejunojejunostomy of Roux-en-Y gastric bypass, and (d) The herniated loop of the biliopancreatic limb after reviving its colour|
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Post-operatively, the patient had a smooth recovery. A gradual introduction of the diet was done successfully. She was discharged home with her baby after 7 days of an uneventful hospital stay.
| Discussion|| |
Acute abdominal pain in pregnancy gives diagnostic and therapeutic challenges. This is in view of the masked picture by the physiologic changes of pregnancy and the developing foetus. It is not uncommon to have non-obstetric causes for abdominal pain during the period of gestation with an incidence of 1 in 500–635 pregnancies. Hence, an early surgical consultation is vital to rule out conditions that might warrant urgent operative intervention, in order to have favorable outcomes for both the mother and her fetus.
Nowadays, the number of women who are undergoing bariatric surgery is increasing. Along with the significant weight loss achieved, fertility improves and the chance of conception rises. As a consequence, possible nutritional and surgical complications might develop [Table 1].
IH is one of the serious complications after RYGB, with an incidence ranging from 0.5% to 10%. It commonly happens 1–2 years after surgery due to the greater weight loss at that time, leading to rapid reduction of the intra-abdominal fat and enlargement of potential mesenteric spaces. In pregnancy, IH is a rare complication mostly occurring during the third trimester and can result in maternofoetal morbidity and documented mortality.,
There are three anatomical sites where IH after RYGB surgery can occur through; these are the transverse mesocolon, inter-mesenteric jejunostomy or Petersen's space between the mesentery of the Roux limb and the transverse mesocolon [Figure 3]. Despite the routine closure of mesenteric defects during the primary surgery, internal herniation can still occur. IH through Petersen's space is considered the most common type encountered.
|Figure 3: Sites of internal hernias including mesocolic window (green arrow) Petersen's mesenteric defect (blue arrow) and enteroenterostomy or distal anastomosis mesenteric defect (red arrow). Reference: Comeau, E. et al. Symptomatic internal hernias after laparoscopic bariatric surgery. Surg Endosc 2005;19:34-9|
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A higher chance of IHs was found in retrocolic RYGB than in patients undergoing antecolic Roux limb orientation., However, IHs remain a life-long risk.
A recent systematic review by Dave et al. included 27 articles, with a total of 59 women, who developed IH during pregnancy after RYGB was identified. The most common presentation was epigastric pain (52.5%) with associated nausea and vomiting (70.27%).
In regard to laboratory tests, elevated white blood cell counts and serum lactate levels were only found in 31.25% and 10% of the cases, respectively. Hence, laboratory investigations are less likely to help in diagnosing IH.
Abdominal imaging such as ultrasound, computed tomography, or magnetic resonance imaging can show signs of bowel obstruction, and intra-abdominal free fluid and help in excluding other pathology (such as biliary disease). However, their use needs to be carefully considered during pregnancy because of radiation exposure and possible contrast adverse reactions.,,
While negative radiological studies cannot exclude IH, a diagnostic laparoscopy or laparotomy is recommended, especially in a patient with persistent abdominal pain.
In Vannevel systemic review, two maternal and three perinatal deaths were reported, all in women treated late, 48 h after the onset of the symptoms. Therefore, an early surgical exploration is necessary in this particular and uncommon situation whenever suspected to reduce the risk of bowel ischaemia as well as maternal and foetal adverse outcomes.
| Conclusion|| |
Internal herniation after RYGB exemplifies a rare, high-risk complication that might occur in pregnancy; hence, an early surgical consultation is recommended. Multidisciplinary management, including obstetricians and bariatric surgeons, is crucial to prevent maternofoetal morbidity and mortality.
We thank the patient for allowing us to share her medical information for the purpose of this study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]