- Email: [email protected]
Laparoscopic single-incision repair of internal hernia defects using an intracorporeal suturing technique
Surgery for Obesity and Related Diseases 7 (2011) 778 –780
Video case report
Laparoscopic single-incision repair of internal hernia defects using an intracorporeal suturing technique Kevin Tymitz, M.D.*, Kimberley Steele, M.D., Michael Schweitzer, M.D. Department of Bariatric Surgery, Johns Hopkins University, Baltimore, Maryland Received July 25, 2011; accepted July 25, 2011
Keywords:
Internal hernia; Laparoscopic Roux-en-Y gastric bypass; Mesenteric defect; Single incision laparoscopic surgery
An internal hernia after laparoscopic Roux-en-Y gastric bypass can occur in ⱕ9% of patients [1,2]. Laparoscopic closure of potential defects at gastric bypass surgery has been shown to reduce the rate of this potentially devastating complication. Despite advances in radiologic imaging, it still can be very difficult to diagnose an internal hernia in a patient who complains of intermittent crampy periumbilical pain but has no significant findings on the abdominal computed tomography scan. Exploration by laparoscopy or laparotomy is typically performed to establish the diagnosis and then to treat this complication, often subjecting the patient to another major operation. Single-incision laparoscopic surgery (SILS, Covidien, Norwalk, CT) is an emerging technology that offers a cosmetically appealing single incision that might also offer decreased pain in the immediate postoperative state. This technique has been successful for multiple bariatric procedures [3–5]. Intracorporeal knot tying is an advanced laparoscopic skill that can be difficult to learn. The single-incision technique removes the normal triangulation angles used in laparoscopic surgery and makes intracorporeal suturing even more of a challenge. The use of the Endostitch (Covidien) during single-incision surgery can make intracorporeal knot tying easier and faster. During a SILS procedure, a reticulating instrument is necessary to allow the surgeon to sew. This helps grasp the tissue and grasp the suture during knot tying.
*Correspondence: Kevin Tymitz, M.D., Department of Bariatric Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224. E-mail: [email protected]
Case report A 38-year-old morbidly obese woman (preoperative body mass index of 42 kg/m2) underwent uneventful antecolic antegastric laparoscopic Roux-en-Y gastric bypass. The mesenteric defect between the transverse mesocolon and the Roux limb mesentery (Peterson’s space), as well as the mesenteric defect of the jejunojejunostomy, were closed with nonabsorbable suture (Surgidac, Covidien). The patient had excellent results and lost approximately 70% of her excess body weight within 2 years (body mass index 23 kg/m2). The patient presented to our clinic with the complaint of intermittent periumbilical abdominal pain, sometimes cramping in nature. The episodes lasted 30 – 60 minutes at a time. She underwent diagnostic tests, including upper endoscopy and computed tomography, with unremarkable findings. Given her ongoing symptoms and negative test results, diagnostic surgery was warranted (Video 1). The patient was placed in the standard supine position for the procedure. A transumbilical incision was made and the fascia opened a couple of centimeters under direct visualization. Next, a SILS port (Covidien) was placed through the defect. Three 5-mm blunt trocars were placed after insufflating the abdomen, followed by a 5-mm, 45° laparoscope. The Roux limb was identified and followed up to the gastric pouch. The remnant stomach was not dilated, and no ulcerations were visualized around the pouch, distal stomach, or duodenum. Attention was then drawn to Peterson’s space, where a large defect was seen between the transverse mesocolon and the Roux limb. A 5-mm port was removed, and a 12-mm port was placed in the SILS device. The defect was then
1550-7289/11/$ – see front matter © 2011 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery. doi:10.1016/j.soard.2011.07.011
K. Tymitz et al. / Surgery for Obesity and Related Diseases 7 (2011) 778 –780
779
closed with the Endostitch using multiple interrupted 2-0 nonabsorbable sutures. The Roux limb was then followed distally to the jejunojejunostomy, where an internal hernia defect was identified in the previously closed mesentery between the biliopancreatic limb and the Roux common channel small bowel. This could easily entrap a loop or loops of small intestine. The defect was closed with the Endostitch device using interrupted 2-0 nonabsorbable suture. The anastomosis appeared to be patent, wide open, and without signs of stricture. Once the defects were closed, the biliopancreatic limb was followed to the ligament of Treitz to ensure no kinks or strictures were present. Likewise, the common channel was followed down to the ileocecal valve. The trocars and port device were then removed, and the abdomen was allowed to desufflate. The fascia was closed with interrupted suture, and the umbilical stalk tacked back to the fascia. The skin was closed with 4-0 absorbable suture, and glue was used as a sterile dressing. We obtained an excellent cosmetic result (Fig. 1). Discussion Mesenteric defects occurring after Roux-en-Y gastric bypass are, at times, technically difficult and can be timeconsuming to close at the end of the operation. The possible mesenteric defects include 2 after an antecolic approach and 3 after a retrocolic approach (Fig. 2) [6]. With fewer potential spaces, it has been shown that fewer internal hernias occur after the antecolic approach [7]. Internal hernias occurring after Roux-en-Y gastric bypass are often difficult to diagnose. Computed tomography can fail to display the classic mesenteric swirling pattern (Fig. 3) used to diagnose internal hernias. For patients with recurrent crampy periumbilical abdominal pain and normal imaging studies, exploratory surgery in the form of laparoscopy or laparotomy is sometimes the only means of diagnosis.
Fig. 1. View of abdomen 2 weeks after surgery.
Fig. 2. Potential mesenteric defects. Reprinted with permission.6
The present case demonstrates the use of a SILS platform to run the entire small bowel, including the Roux limb, biliopancreatic limb, and common channel. Also demonstrated is an intracorporeal suturing and knot tying technique that is also safe and effective using a single-incision laparoscopic technique. This can provide an alternative and less invasive technique to the diagnosis and possible treat-
Fig. 3. Computed tomography image demonstrating mesenteric swirling.
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K. Tymitz et al. / Surgery for Obesity and Related Diseases 7 (2011) 778 –780
ment of postgastric bypass patients who present with possible internal hernias.
Disclosures K. Tymitz has no commercial associations that might be a conflict of interest in relation to this article; M. Schweitzer received research from the Empower study: Enteromedics and was the primary investigator at Johns Hopkins University for a multicenter trial; K. Steele has no commercial associations that might be a conflict of interest in relation to this article.
Appendix Supplementary data The video associated with this article can be found, in the online version, at www.SOARD.org under “Multimedia Library.”
References [1] Cho M, Pinto D, Carrodeguas L, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Dis 2006;2:87–91. [2] Carmody B, DeMaria EJ, Johnson JM, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005;1:511–16. [3] De la Torre RA, Satgunam S, Morales MP, et al. Transumbilical single-port laparoscopic adjustable gastric band placement with liver suture retractor. Obes Surg 2009;19:1701–10. [4] Huang CK, Houng JY, Chiang CJ, Chen YS, Lee PH. Single incision transumbilical laparoscopic Roux-en-Y gastric bypass: a first case report. Obes Surg 2009;19:1711–15. [5] Gentileschi P, Camperchioli I, Domenico B, Di Lorenzo N, Sica G, Gaspari AL. Laparoscopic single-port sleeve gastrectomy for morbid obesity: preliminary series. Surg Obes Relat Dis 2010;6:665– 69. [6] Schweitzer MA, DeMaria EJ, Sugerman HA, Sugerman HJ. Laparoscopic closure of mesenteric defects after Roux-en-Y gastric bypass. J Laparoendosc Adv Surg Tech A 2000;10:173–5. [7] Steele KE, Prokopowicz GP, Magnuson T, Lidor A, Schweitzer M. Laparoscopic antecolic Roux-en-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach. Surg Endosc 2008;22:2056 – 61.
Video case report
Laparoscopic single-incision repair of internal hernia defects using an intracorporeal suturing technique Kevin Tymitz, M.D.*, Kimberley Steele, M.D., Michael Schweitzer, M.D. Department of Bariatric Surgery, Johns Hopkins University, Baltimore, Maryland Received July 25, 2011; accepted July 25, 2011
Keywords:
Internal hernia; Laparoscopic Roux-en-Y gastric bypass; Mesenteric defect; Single incision laparoscopic surgery
An internal hernia after laparoscopic Roux-en-Y gastric bypass can occur in ⱕ9% of patients [1,2]. Laparoscopic closure of potential defects at gastric bypass surgery has been shown to reduce the rate of this potentially devastating complication. Despite advances in radiologic imaging, it still can be very difficult to diagnose an internal hernia in a patient who complains of intermittent crampy periumbilical pain but has no significant findings on the abdominal computed tomography scan. Exploration by laparoscopy or laparotomy is typically performed to establish the diagnosis and then to treat this complication, often subjecting the patient to another major operation. Single-incision laparoscopic surgery (SILS, Covidien, Norwalk, CT) is an emerging technology that offers a cosmetically appealing single incision that might also offer decreased pain in the immediate postoperative state. This technique has been successful for multiple bariatric procedures [3–5]. Intracorporeal knot tying is an advanced laparoscopic skill that can be difficult to learn. The single-incision technique removes the normal triangulation angles used in laparoscopic surgery and makes intracorporeal suturing even more of a challenge. The use of the Endostitch (Covidien) during single-incision surgery can make intracorporeal knot tying easier and faster. During a SILS procedure, a reticulating instrument is necessary to allow the surgeon to sew. This helps grasp the tissue and grasp the suture during knot tying.
*Correspondence: Kevin Tymitz, M.D., Department of Bariatric Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224. E-mail: [email protected]
Case report A 38-year-old morbidly obese woman (preoperative body mass index of 42 kg/m2) underwent uneventful antecolic antegastric laparoscopic Roux-en-Y gastric bypass. The mesenteric defect between the transverse mesocolon and the Roux limb mesentery (Peterson’s space), as well as the mesenteric defect of the jejunojejunostomy, were closed with nonabsorbable suture (Surgidac, Covidien). The patient had excellent results and lost approximately 70% of her excess body weight within 2 years (body mass index 23 kg/m2). The patient presented to our clinic with the complaint of intermittent periumbilical abdominal pain, sometimes cramping in nature. The episodes lasted 30 – 60 minutes at a time. She underwent diagnostic tests, including upper endoscopy and computed tomography, with unremarkable findings. Given her ongoing symptoms and negative test results, diagnostic surgery was warranted (Video 1). The patient was placed in the standard supine position for the procedure. A transumbilical incision was made and the fascia opened a couple of centimeters under direct visualization. Next, a SILS port (Covidien) was placed through the defect. Three 5-mm blunt trocars were placed after insufflating the abdomen, followed by a 5-mm, 45° laparoscope. The Roux limb was identified and followed up to the gastric pouch. The remnant stomach was not dilated, and no ulcerations were visualized around the pouch, distal stomach, or duodenum. Attention was then drawn to Peterson’s space, where a large defect was seen between the transverse mesocolon and the Roux limb. A 5-mm port was removed, and a 12-mm port was placed in the SILS device. The defect was then
1550-7289/11/$ – see front matter © 2011 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery. doi:10.1016/j.soard.2011.07.011
K. Tymitz et al. / Surgery for Obesity and Related Diseases 7 (2011) 778 –780
779
closed with the Endostitch using multiple interrupted 2-0 nonabsorbable sutures. The Roux limb was then followed distally to the jejunojejunostomy, where an internal hernia defect was identified in the previously closed mesentery between the biliopancreatic limb and the Roux common channel small bowel. This could easily entrap a loop or loops of small intestine. The defect was closed with the Endostitch device using interrupted 2-0 nonabsorbable suture. The anastomosis appeared to be patent, wide open, and without signs of stricture. Once the defects were closed, the biliopancreatic limb was followed to the ligament of Treitz to ensure no kinks or strictures were present. Likewise, the common channel was followed down to the ileocecal valve. The trocars and port device were then removed, and the abdomen was allowed to desufflate. The fascia was closed with interrupted suture, and the umbilical stalk tacked back to the fascia. The skin was closed with 4-0 absorbable suture, and glue was used as a sterile dressing. We obtained an excellent cosmetic result (Fig. 1). Discussion Mesenteric defects occurring after Roux-en-Y gastric bypass are, at times, technically difficult and can be timeconsuming to close at the end of the operation. The possible mesenteric defects include 2 after an antecolic approach and 3 after a retrocolic approach (Fig. 2) [6]. With fewer potential spaces, it has been shown that fewer internal hernias occur after the antecolic approach [7]. Internal hernias occurring after Roux-en-Y gastric bypass are often difficult to diagnose. Computed tomography can fail to display the classic mesenteric swirling pattern (Fig. 3) used to diagnose internal hernias. For patients with recurrent crampy periumbilical abdominal pain and normal imaging studies, exploratory surgery in the form of laparoscopy or laparotomy is sometimes the only means of diagnosis.
Fig. 1. View of abdomen 2 weeks after surgery.
Fig. 2. Potential mesenteric defects. Reprinted with permission.6
The present case demonstrates the use of a SILS platform to run the entire small bowel, including the Roux limb, biliopancreatic limb, and common channel. Also demonstrated is an intracorporeal suturing and knot tying technique that is also safe and effective using a single-incision laparoscopic technique. This can provide an alternative and less invasive technique to the diagnosis and possible treat-
Fig. 3. Computed tomography image demonstrating mesenteric swirling.
780
K. Tymitz et al. / Surgery for Obesity and Related Diseases 7 (2011) 778 –780
ment of postgastric bypass patients who present with possible internal hernias.
Disclosures K. Tymitz has no commercial associations that might be a conflict of interest in relation to this article; M. Schweitzer received research from the Empower study: Enteromedics and was the primary investigator at Johns Hopkins University for a multicenter trial; K. Steele has no commercial associations that might be a conflict of interest in relation to this article.
Appendix Supplementary data The video associated with this article can be found, in the online version, at www.SOARD.org under “Multimedia Library.”
References [1] Cho M, Pinto D, Carrodeguas L, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Dis 2006;2:87–91. [2] Carmody B, DeMaria EJ, Johnson JM, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005;1:511–16. [3] De la Torre RA, Satgunam S, Morales MP, et al. Transumbilical single-port laparoscopic adjustable gastric band placement with liver suture retractor. Obes Surg 2009;19:1701–10. [4] Huang CK, Houng JY, Chiang CJ, Chen YS, Lee PH. Single incision transumbilical laparoscopic Roux-en-Y gastric bypass: a first case report. Obes Surg 2009;19:1711–15. [5] Gentileschi P, Camperchioli I, Domenico B, Di Lorenzo N, Sica G, Gaspari AL. Laparoscopic single-port sleeve gastrectomy for morbid obesity: preliminary series. Surg Obes Relat Dis 2010;6:665– 69. [6] Schweitzer MA, DeMaria EJ, Sugerman HA, Sugerman HJ. Laparoscopic closure of mesenteric defects after Roux-en-Y gastric bypass. J Laparoendosc Adv Surg Tech A 2000;10:173–5. [7] Steele KE, Prokopowicz GP, Magnuson T, Lidor A, Schweitzer M. Laparoscopic antecolic Roux-en-Y gastric bypass with closure of internal defects leads to fewer internal hernias than the retrocolic approach. Surg Endosc 2008;22:2056 – 61.