Diagnosing internal herniation after Roux-en-Y gastric bypass surgery: Literature overview, cadaver study and the added value of 3D CT angiography

Cornelis Klop*, Laura N. Deden, Edo O. Aarts, Ignace M.C. Janssen, Milan E.J. Pijl, Anneline van den Ende, Bart P.L. Witteman, Gabie M. de Jong, Theo J. Aufenacker, Cornelis H. Slump, Frits J. Berends

*Corresponding author for this work

    Research output: Contribution to journalArticleAcademicpeer-review

    5 Citations (Scopus)
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    Purpose The purposes of the study are to outline the complexity of diagnosing internal herniation after Roux-en-Y gastric bypass (RYGB) surgery and to investigate the added value of computed tomography angiography (CTA) for diagnosing internal herniation. Materials and Methods A cadaver study was performed to investigate the manifestations of internal hernias and mesenteric vascularization. Furthermore, a prospective, ethics approved study with retrospective interpretation was conducted. Ten patients, clinically suspected for internal herniation, were prospectively included. After informed consent was obtained, these subjects underwent abdominal CT examination, including additional arterial phase CTA. All subjects underwent diagnostic laparoscopy for suspected internal herniation. The CTA was used to create a 3D reconstruction of the mesenteric arteries and surgical staples (3D CTA). The 3D CTA was interpreted, taking into account the presence and type of internal hernia that was found upon laparoscopy. Results Cadaveric analysis demonstrated the complexity of internal herniation. It also confirmed the expected changes in vascular structure and surgical staple arrangement in the presence of internal herniation. 3D CTA studies of the subjects with active internal hernias demonstrated remarkable differences when compared to control 3D CTA studies. The blood supply of herniated intestinal limbs in particular showed abnormal trajectories. Additionally, enteroenterostomy staple lines had migrated or altered orientation. Conclusion 3D CTA is a promising technique for diagnosing active internal hernias. Our findings suggest that for diagnosing internal hernias, focus should probably shift from routine abdominal CT examination towards the 3D assessment of the mesenteric vasculature and surgical staples.

    Original languageEnglish
    Pages (from-to)1822-1830
    Number of pages9
    JournalObesity Surgery
    Issue number7
    Early online date5 Feb 2018
    Publication statusPublished - Jul 2018


    • UT-Hybrid-D
    • Cadaver study
    • Closure
    • Complication
    • Computed tomography
    • Internal herniation
    • Literature overview
    • Mesenteric defect
    • Petersen’s space
    • Roux-en-Y gastric bypass
    • Angiography


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