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Counter-Clockwise Rotation of Roux-en-Y Limb Significantly Reduces Internal Herniation in Laparoscopic Roux-en-Y Gastric Bypass (LRYGB)
Kalyana Nandipati*, Edward Lin, Farah a. Husain, Jahnavi Srinivasan, John F. Sweeney, S. S. Davis
General Surgery, Emory University, Decatur, GA

Introduction: Internal hernias continue to be a significant source of morbidity after LRYGB. Literature addressing the technique of Roux limb construction as a predisposing factor is sparse. The objective of this study is to evaluate the impact of Roux limb construction technique on the development of internal hernias.Methods: In this study we included 444 consecutive patients (367 (82.7%) females and 77 (17.3%) males) from bariatric database who underwent LRYGB at our Institution. Variables collected include demographics, body mass index (BMI) before and after the procedure, and postoperative small bowel obstruction secondary to internal herniation. Technical details collected include; type of roux-en-y limb construction, Peterson’s defect closure at initial operation and reoperative findings. Roux limbs were constructed in 291 patients by a clockwise rotation of the bowel and jejuno-jejunostomy performed on the right side of the axis of the mesentery (Group 1). In 153 patients the Roux limb was constructed by a counterclockwise rotation of the Roux limb resulting in the jejuno-jejunostomy on the left side of the axis of the mesentery (Group 2). We also analyzed the impact of Peterson’s space closure on internal hernias. Fisher’s exact test and Chi-square test used for the analysis.Results: Of a total 444 [mean age - 43.7 + 10.3 years, mean BMI pre op was 46.4 + 5.1, BMI after median follow up of 12 months was 34.5 + 6.98] patients included in the study, 21 (4.7%) internal hernias were identified. Of 21 internal hernias, 17 (81%) were through Peterson’s space and 4 (19%) were through mesenteric defect. Group 1 patients had significantly higher overall internal hernias (20/291, 6.9% vs 1/153, 0.7%; P = 0.0018) and Peterson’s hernias (16/275, 5.8% vs 1/152, 0.6%; P = 0.0089) compared to Group 2. In addition, no significant difference was noted in the incidence of Peterson’s hernia whether the defect was closed or not closed (closed group - 4/117, 3.4% vs. not closed - 13/327, 4%; P = 1.00). Within Peterson’s defect closed group, clockwise rotation and anastomosis to the right side of axis of mesentery was associated with significantly higher incidence of Peterson’s hernias compared to counter clockwise rotation (4/54 vs 0/63, P = 0.043). In not closed group, clockwise rotation was associated with higher incidence of internal hernias that did not reach statistical significance (12/237, 5.1% vs 1/90, 1.1%; P = 0.12).Summary: This study demonstrates that the technique for construction of the Roux limb probably is a major factor in the development of internal hernias. Construction of the Roux limb with a counter-clockwise rotation of the bowel, such that both jejuno-jejunostomy anastomosis and Ligament of Treitz are to the left of the axis of the mesentery significantly reduces the incidence of internal hernias.


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