Procedure

Laparoscopy
Reduce obvious hernia
Assess viability of bowel and consider resection is indicated
If i am unclear if there is a hernia or not
- I would run the small bowel from the IC valve to the JJ anastomosis
- DJ flexure to the JJ anastomosis
- From the stomach to the JJ anastomosis
I would the check the three defects and suture them close if open
- Petersen’s Space (Transverse Colon and Roux limb mesentery)
- Mesenteric defect behind the jej-jej anastomosis
- Mesocolic space (if retrocolic)

Information

Occurs in 2% (usually months/years later)
- Massive weight loss creates long floppy mesentery with loose ligaments
Presentation non-specific
- Suspect in any bypass with vomiting or abdominal pain
Investigations
- CT scan (70-80% sensitive), signs can be subtle and difficult to diagnose
  - Needs to go to OT if evidence of SBO on CT
  - Mesenteric swirl sign, retroperitoneal stranding
  - Increased volume of bowel in LUQ
  - Closed-loop internal hernia
- Diagnostic laparoscopy
Occurs in 3 locations:
- Petersen’s Space (Transverse Colon and Roux limb mesentery)
- Mesenteric defect behind the jej-jej anastomosis
- Mesocolic space (if retrocolic)

Mesenteric defects: A) transverse mesocolic; B) Petersen’s space; and C) jejunojejunostomy mesentery

Needs to go to OT as can decompress biliary limb AND increased risk of vascular compromise
Risk lower in laparoscopic cases and if mesenteric defects closed
- But can never prevent 100% risks