We present a 31-year-old woman with a history of single-anastomosis Billroth 2 gastrointestinal bypass surgery, who underwent surgery at another hospital four years ago. After surgery there was a significant weight loss of 55 kg with a BMI of 30.4.
The patient went to the Emergency Department of our hospital for abdominal pain of 48 hours of evolution. The pain was located in the mesogastrium, right iliac fossa (RIF) and both lumbar fossa. She was afebrile, without nausea or vomiting and with intestinal transit present.
On examination the patient was in good general condition, afebrile, hemodynamically stable, conscious and oriented. The abdomen was soft and depressible, it was felt a mass of about 5 cm in mesogastric and in RIF, that was painful on palpation.
In the imaging tests, a suspicion of ileal invagination was identified by abdominal ultrasound (figure 1). It was appreciated a grouping of adenopathies that together amounted to 42 x 8 mm in mesogastric, which formed the head of the invagination. It was also presented a sheet of free liquid in proximity and it wasn’t be signs of intestinal obstruction.
Due to the diagnostic suspicion of an ileoileal invagination, the patient was operated urgently. An internal hernia was identified through the Petersen space during diagnostic laparoscopy. In addition, there was a discrete amount of chyloid ascities at the subdiaphragmatic level and in the right gutter. We reduced completely the small bowel loops that produced the internal hernia by Petersen's space (figure 2) and we closed the Petersen's space with continuous monofilament suture 2-0 (figure 3).
After the intervention the patient presented a favorable clinical evolution, with good tolerance to the oral diet, so that on the third postoperative day she was discharged from the hospital.
The patient underwent clinical controls in a surgical outpatient clinic and was asymptomatic.
We present a 36-year-old woman with a history of laparoscopic Roux-en-Y gastric bypass surgery at another hospital 3 years ago. The patient presented as a late complication an ulcer in the gastrojejunal anastomosis with medical management.
The patient went to the Emergency Department of our hospital for continuous abdominal pain located in the epigastrium with hemicint irradiation towards the back, associating nausea and vomiting. She was afebrile and had intestinal transit.
On examination, the patient was in good general condition, afebrile, hemodynamically stable, conscious and oriented. The abdomen was soft and depressible, painful to the palpation in a generalized way, being more accentuated in epigastrium, without abdominal defense.
In the abdominopelvic CT with intravenous contrast, was observed findings compatible with left transmesenteric internal hernia with minimal free fluid in the pelvis (Figure 4). In the analysis was observed anemia with hemoglobin 10.6 g/dl, the rest of parameters were normal.
Due to the diagnostic suspicion of an internal transmesenteric hernia, we decided operate urgently. In the diagnostic laparoscopy we observed an internal hernia through the mesenteric gap of the loop foot with almost complete hernia of the entire intestine and twisted mesentery root (figure 5). We also observed abundant amounts of chylose ascites (figure 6).
Due to the difficulty of the surgical technique by laparoscopy, we decided to convert to mid-supraumbilical laparotomy, performing complete reduction of the small bowel loops, desrotating the meso and closing the mesenteric gap with continuous suture of unabsorbable monofilament 2-0 (figure 7).
After the intervention in the immediate postoperative period, the patient presented the appearance of a subcutaneous edema and localized abdominal discomfort in both, remaining hemodynamically stable. We observed a decrease in hemoglobin levels up to 6.8 g/dL, so we realized an abdominal angioTAC where was diagnosed a hematoma in the left empty abdominal wall without signs of active bleeding. The patient was clinical and hemodynamic stability, so that, we decided to manage conservatively with transfusion of red blood cells and intravenous iron.
After that, the patient presented a favorable clinical evolution, with a good oral tolerance and normalization in the hemoglobin values. Subsecuently, the patient was discharged from de hospital on the sixth postoperative day.