Management of a Complicated Internal Herniation After Roux-en-Y
Gastric Bypass in a 28-Week Pregnant Woman
Authors: Thomopoulos Theodoros , Mantziari Styliani , St-Amour Penelope , Uldry Emilie , Suter Michel 
Published: September 2020

Abstract
Background
Small bowel obstruction (SBO) due to internal hernia (IH) is a
well-known late complication after laparoscopic Roux-en-Y gastric bypass
(LRYGB), with an incidence between 0.5 and 10% as reported by Iannelli et al.
(Obes Surg. 17(10):1283–6, 2007). It
is reported most frequently 1–2 years after surgery because of the greater
weight loss at that time, with rapid loss of the mesenteric fat consequently as
discussed by Stenberg et al. (Lancet. 387(10026):1397–404, 2016). Currently, women constitute more than
50% of the patients undergoing bariatric surgery and most of them are of
childbearing age as reported by the World Health Organization (2015). SBO, due to IH, is a rare
complication during pregnancy, mostly occurring during the third trimester as
discussed by Torres-Villalobos et al. (Obes Surg 19(7):944–50, 2009), and can result in fetal and maternal
morbidity and even mortality as reported by Vannevel et al. (Obstet Gynecol.
127(6):1013–20, 2016). Moreover, the
physiologic changes of pregnancy can mask the symptoms of SBO after LRYGB,
leading to significant diagnostic and therapeutic delays as detailed by Wax et
al. (Am J Obstet Gynecol 208(4):265–71, 2013). Therefore, an early surgical exploration is necessary
in this particular and uncommon situation as discussed by Webster et al. (Ann R
Coll Surg Engl 97(5):339–44, 2015).

Methods
A 32-year-old female patient, with Ehlers-Danlos syndrome and
chronic pain, was in the 28th week of her first pregnancy after bariatric
surgery. She had had an antecolic LRYGB 6 years ago in another institution,
resulting in a 35-kg weight loss. She presented to the emergency department with
severe and persistent epigastric pain associated with nausea and vomiting during
24 h. On physical examination, her abdomen was painful and tender at the
epigastrium and left hypochondrium, and her vital signs were normal. The blood
tests were in the normal range except the white blood cell count at 12′000 G/l.
The obstetric and neonatal team was involved, and fetal heart monitoring was
normal. Abdominal ultrasonography ruled out other causes of pain. An abdominal
MRI was performed and displayed a distended proximal small bowel, free abdominal
fluid, and bowel mesenteric edema in the left upper quadrant with compression of
the superior mesenteric vein. Internal hernia with intestinal suffering was
suspected, and the patient consented for emergency laparoscopy.

Results
The laparoscopic exploration, reduction of the internal hernia, and
closure of the mesenteric defects are demonstrated step-by-step in the presented
intraoperative video. The postoperative course was uncomplicated for both
patient and fetus. Oral feeding was resumed at day 1, with no residual symptom,
and the patient was discharged on postoperative day 3. At 1-month follow-up, she
had no complaint and her pregnancy had resumed a normal course. She delivered a
healthy baby at 36 weeks without any complication.

Conclusions
Internal herniation after LRYGB represents a rare, high-risk
complication during pregnancy. A low threshold for imaging, preferably by
abdominal MRI, is recommended. Multidisciplinary management, including
obstetricians and bariatric surgeons, is necessary in order to avoid maternal
and fetal adverse outcomes. During surgery, recognition of the anatomy is often
difficult, and parts of the bowel are distended and fragile. Starting to run the
bowel backwards from the ileocecal valve is a crucial surgical step for reducing
internal hernias during LRYGB, and reduces both the risk to worsen the situation
and of bowel injury, making its management less hazardous.