Patient who underwent a ACRYGB at the Warringal or Knox Private Hospital (Melbourne Australia), between January 2014 and July 2018 were included for this study. This timeframe was chosen to ensure a minimum of one year follow up after RYGB surgery and all procedures have been performed laparoscopically since 2014. Patients who did not meet at least one year of follow up were excluded. Ethical approval was obtained for this study at the ethics committee of the Warringal Hospital and Knox private hospital, Melbourne Australia. All procedures were performed by one experienced bariatric surgeon (>1000 cases). Average time for surgery was 73 minutes. Average number of procedures performed per day was Two. All prospectively collected data were logged into a computerized research database starting from January 2014. In case of missing information, a detailed audit of all patients undergoing ACRYGB was also retrospectively reviewed.
During reoperation, a standardized step by step three port approach was used. The defects were always re-examined if the patient underwent further laparoscopy for other reasons or for IHs. This information was also prospectively recorded in the database.
Approach to abdominal complaints
Although a wide range of abdominal complaints may occur, in most cases physicians commonly think it originates from the RYGB. This is especially the case once regular explanations are not found, such as infectious diseases. In our institution, blood withdrawal is routinely performed when acute abdominal complaints occur, including infectious parameters. When complaints like abdominal pain become sustained or recur (after 25ug of fentanyl) or when they do not resolve in several hours, patients undergo a CT scan. When a diagnosis is found the patient is treated accordingly, but when no explanation is found there was a very low threshold for diagnostic laparoscopy.
Definition internal hernia
An IH is defined as a bowel protruding through one (or more) of the defects or presence of chylous fluid with symptoms consistent with an internal hernia. A positive CT scan with mesenteric swirl or confirmed small bowel loops within an open Peterson or EE space are also considered to be diagnostic of an internal hernia when during laparoscopy there was at least one defect present.
ACRYGB without BIO Mesh closure
All patients were operated on, using a standardized operation technique by the same experienced surgeon. A laparoscopic antecolic antegastric RYGB procedure was performed. First Treitz was identified and one meter of small intestine was measured which forms the biliary limb and stapled using a white cartridge (Echelon, Ethicon, Johnson & Johnson, New Brunswick, NJ, USA). Another meter of small intestine was measured from that point onwards, which forms the alimentary limb. The entero-enterotomy was performed with a 60-mm white linear Endo stapler combined with running absorbable suture (V-loc, Medtronic, Minneapolis, MN, USA). The EE defect was then closed with a continuous Novafil V lock suture (Medtronic). The alimentary limb was than sutured to the stomach in preparation of the gastro-jejunostomy. Petersons space was initially not closed but later closed as described below. A small amount of Glubran was also used. A long gastric pouch of 40–50 ml was constructed using a linear stapler along a 40Ch gastric tube. The gastro-jejunostomy was performed with a 60-mm white linear stapler, but only using 30mm of length (ETS, Ethicon, Johnson & Johnson, New Brunswick, NJ, USA) combined with running barbed absorbable suture to close the anterior stapling gap (V-loc, Medtronic, Minneapolis, MN, USA). The integrity of the gastro-jejunostomy and gastric pouch staple line were tested intraoperatively for anastomotic leak with a burst test.
ACRYGB with BIO Mesh closure
The whole procedure was performed in completely the same manner, but the closure technique of Peterson’s space and entero-enterostomy was changed. Closing of Peterson’s space and the entero-enterostomy were performed using a 3*1 and 4*2cm piece of Bio A (GORE® BIO-A®, Newark Delaware USA)mesh ($580) respectively, placed over the sutured (V-loc, Medtronic, Minneapolis, MN, USA) closure and secured with a small amount of Glubran Glue ( N-butyl-2-cyanoacrylate (NBCA). Average time to close the space and place and secure mesh was 6 minutes.
Approach diagnostic laparoscopy
After introduction of the three ports, in most cases a liver retractor appeared unnecessary. First the pouch and gastro-enterotomy was examined and then the alimentary limb was measured, and length noted. Next, Peterson’s space and the entero-enterotomy were examined after Treitz was located, then, the common channel was measured. When too much traction occurred on the small bowel, the ileocolic angle was looked up and from there the common channel was followed up till the entero-enterotomy. With this approach all internal hernias could be solved.
Data were analyzed using IBM® SPSS® (version 22.0 for Windows). Results are presented as mean values ± standard deviation (SD), unless specified otherwise. Descriptive statistics were used for demographic variables. Differences between groups were analyzed by Student’s t tests for continue variables and Fisher’s exact tests for categorical data. To adjust for the baseline covariates, i.e., age, sex, preoperative BMI, and preoperative diabetes, a linear regression analysis was performed. All tests were two tailed and a p value < 0.05 was considered as statistically significant.