Internal Hernias and Angina Abdominis After Laparoscopic Gastric Bypass: The Challenging Management of an Underestimated Problem

Introduction:. Internal hernia represents one of the most common late complications of Roux-en-Y gastric bypass (RYGBP), with an estimated incidence varying from 0.7% to 3.25%, reaching 6% considering only procedures with transmesocolic alimentary loop [1-2-3]. Such incidence only account for complicated hernias, while a greater part of internal hernias occur (si manifesta) as a recurrent episode of postprandial colic pain (angina abdominis). Those latter cases are probably the most challenging to diagnose, to treat and to prevent.. Case series: we present a video of four cases of laparoscopic exploration in patients with recurrent, not complicated, postprandial abdominal pain (angina abdominis) after RYGB. All the patients were mid age (mean age 39.5) females, previously submitted to an antecolic RYGB; mean EWL was 83%. Preoperative study revealed in all cases a partial or complete twist of the mesenteric axis at CT san. None presented with an acute syndrome (occlusion, leucocytosis, shock) and they were all operated on a not urgent setting. A Petersen non complicated hernia was detected in three patients, and reduction with stitch fixation was performed, while an adhesion to an intraperitoneal mesh with loop rotation was detected in the last case, and treated by a laparoscopic adhesiolysis. Postoperative course was uneventful for all the patients (mean hospital stay 2.5 days), and abdominal pain resolution was achieved at follow-up. Conclusions: Laparoscopic exploration yields a sure diagnosis and a safe and effective treatment of non complicated internal hernias after RYGBP.