Finally, the proximal end of the jejunum is reattached to the remainder of the intestine 30 cm distal to the initial division using a similar technique Fig. In all the patients we report, the jejunojejunal mesenteric defect was closed during the procedure under direct vision using a nonabsorbable running suture Ethibond; Ethicon or absorbable intermittent sutures Vicryl; Ethicon , and sometimes under laparoscopic vision in the case of obese patients, at the discretion of the operating surgeon.
All the patients underwent routine computed tomography CT scan or abdominal ultrasonography US 6 months postoperatively as part of the routine evaluation. Patients who underwent reoperation because of symptoms and CT findings consistent with internal hernia were reviewed.
There were no internal hernia patients who were diagnosed by CT scan without symptoms. The patients who experienced internal hernia were reviewed in two groups.
In this study, patients were reviewed from January to June Six patients underwent surgical treatment of internal hernia after gastrectomy for gastric cancer, including 2 women and 4 men, aged 47—73 years median, Internal hernia occurred for 6 2.
The mean observation period was 1, days range, —3, in the no-closure group. The mean time to diagnosis of internal hernia was days range, 2— Table 1. Except the first case, all the other internal hernia patients presented with colicky pain.
The radiologic findings were abnormal for the patients, with dilation of the small bowel, remnant stomach, or both, and twisted appearance of the mesentery and its vessels, suggesting a volvulus Fig. No adhesions were noted at reoperation for any of the patients. Early phase of enhanced computed tomography CT scan shows swirled appearance and twisting of the mesenteric artery arrow , whirl sign in a patient days after laparoscopy-assisted distal gastrectomy LADG.
Internal hernia site after antecolic Roux-en-Y reconstruction R-Y. No severe complications occurred after LADG. One patient in the non-closure group required reoperation because of leakage at gastrojejunostomy after TLDG.
This series had no mortality. During the past decade, laparoscopic distal gastrectomy has gained acceptance and many studies have shown several advantages over the open approach to the same surgery, such as reduction in postoperative pain and earlier resumption of normal activities.
Several randomized controlled studies of LADG showed further benefits including less bleeding and improved quality of life compared with a traditional open distal gastrectomy [ 1 — 3 ]. In Japan, B-I reconstruction has typically been performed after laparoscopic distal gastrectomy.
Therefore, the incidence of internal hernia after laparoscopic distal gastrectomy was quiet low. Because of high rates of remnant gastritis after B-I reconstruction, R-Y reconstruction has gradually gained favor for use and has been one of the standard methods of reconstruction after laparoscopic distal gastrectomy [ 4 — 6 ]. Thus, there is the possibility of internal hernia after laparoscopic distal gastrectomy with R-Y reconstruction. Laparoscopic RYGBP reportedly has a high rate of postoperative internal hernia with an incidence of 3.
These authors reported 7. The reason why the incidence of internal hernia is higher in laparoscopic RYGBP may be that laparoscopy decreases tissue trauma and therefore causes fewer adhesions than open surgery [ 9 ]. Body weight loss may be another risk factor for patients with a postgastrectomy internal hernia. Miyagaki et al. In our study, the reduction after distal gastrectomy was The large decrease in mesenteric fat after distal gastrectomy is a major cause of weight loss after surgery [ 17 , 18 ].
As a result, a large weight loss may increase the size of the mesenteric defect, thus accelerating the internal hernia [ 19 ]. As for the route, the antecolic route may be better because it eliminated one of the most common sites for herniation, the mesocolon, as for laparoscopic distal gastrectomy with R-Y reconstruction. Moreover, Paroz et al. Hosoya et al. Log in Sign up. Articles Cases Courses Quiz. About Recent Edits Go ad-free.
Edit article. View revision history Report problem with Article. Citation, DOI and article data. Di Muzio, B. Petersen hernia. Reference article, Radiopaedia. Petersen's hernia Petersen hernias Petersen herniation Peterson's hernia Peterson herniation Peterson hernia.
Emergency laparotomy was done, and an internal herniation of the small intestine through Petersen space was observed. A man in his 50s was referred to our hospital due to a complaint of severe sudden abdominal pain.
On CT, internal herniation of the small intestine was suspected. During emergency laparotomy, an internal herniation of the bowel through the Petersen space was observed. Though history of R-Y reconstruction surgery may be helpful, preoperative diagnosis of Petersen hernia is difficult to establish.
Here we present two rare cases of this type of internal hernia. In , Dr. Walther Petersen, a German surgeon, first described Petersen space hernia which is an internal hernia caused by the Petersen defect, a space between the Roux limb and the transverse mesocolon formed after Roux-en Y R-Y reconstruction Petersen This is a rare internal hernia that occurs after any type of gastrojejunostomy.
Internal hernias after laparoscopic gastrectomy with R-Y reconstruction in bariatric surgery have been reported frequently, but reports about these after open surgery for gastric cancer are a few. To our knowledge, reports on internal hernia, especially Petersen hernia, after open gastrectomy for gastric cancer treated with R-Y reconstruction are a few.
We report two cases of Petersen hernia after laparotomy for gastric cancer treated with R-Y reconstruction. A man in his 70s was referred to our emergency department due to postprandial sudden abdominal pain.
Laboratory investigations revealed nonspecific findings, with a slight elevation of the inflammatory status CRP 2. He had a history of open total gastrectomy with R-Y reconstruction with an antecolic jejunal limb for gastric corpus cancer a year prior to his presentation at our hospital and coronary bypass operation. The body mass index BMI was Other medical and family histories were unremarkable. Accordingly, bowel obstruction and strangulation of the small intestine were suspected Fig.
Emergency laparotomy showed an internal herniation of the small intestine through the Petersen space formed by transverse mesocolon and Roux jejunal limb from the left to the right side Fig. The herniated small intestine had more than one rotation. There was no color change suggesting the possibility of extensive bowel necrosis. The bowel obstruction was relieved, and the defect was closed by suturing.
Since the operation, the patient was followed up regularly. No recurrence of bowel obstruction was observed for almost 2 years. However, the patient presented with adhesive bowel obstruction three times since then, and every time, the symptoms were relieved conservatively. The dilated small intestine with a thickened bowel wall arrow with a high density area of mesenteric fat presenting with edematous changes asterisk.
Strangulation of the small intestine and mesenteric fat, and vascular structures presenting as the whirl sign circle can also be identified. Intraoperative image of case 1. The small bowel herniating through the Petersen defect arrow. A man in his 50s was referred to our emergency department due to a sudden onset of severe abdominal pain.
Laboratory investigations revealed non-specific findings CRP 9. He had been followed up for outpatient visits and received TS The BMI was The duration of follow-up was recorded as the time from gastrectomy until death or the last registered follow-up at the postoperative outpatient clinic or by telephone, whichever came first.
The secondary endpoints were postoperative complications within 30 days of gastrectomy. PH was defined as an internal hernia located at the PD and was confirmed by surgical exploration. These patients were not confirmed by surgery.
Early postoperative complications were classified according to the Clavien-Dindo surgical complication grading system [ 22 ]. When a patient had two or more postoperative complications, the higher grade was recorded [ 23 ]. Categorical variables are presented as numbers with percentages, and continuous data are presented as means with the standard deviation SD. A logistic regression analysis was performed to test the univariate and multivariate associations between variables to identify risk factors for PH and SPH.
Data were analyzed using SPSS A total of patients were enrolled in our study. The non-closure group included patients, and the closure group included patients. The demographic data of the entire patient population are presented in Table 1. There were no significant differences between the two groups with respect to sex, age, BMI, previous abdominal surgery, surgical approach, reconstruction type, extent of lymphadenectomy, tumor diameter, tumor location, macroscopic type, tumor differentiation, TNM stage, or postoperative adjuvant chemotherapy.
Table 2 shows the detailed information of complications occurring within 30 days of gastrectomy. In the non-closure group, which included patients, 11 patients 1. After routine PD closure in patients in the closure group, one patient 0. Table 3 shows the characteristics of patients with PH. Eleven patients in the non-closure group and one patient in the closure group developed PH. The PD was found to be open during the operation Fig. We closed all PDs after the reduction of the herniated bowels, and no PH recurrence was observed until the end of the study.
Among them, 10 patients underwent emergency surgery, and two patients underwent elective surgery. The two patients in the elective surgery group were diagnosed with SPH before surgery according to previous diagnostic criteria [ 10 , 11 , 19 , 20 , 21 ], and they were confirmed to have PH by surgical exploration. Table 4 shows the results of univariate and multivariate analyses to identify the independent risk factors for PH and SPH.
Sex, age, BMI, previous abdominal surgery, surgical approach, reconstruction type, and the extent of lymphadenectomy were not associated with PH and SPH occurrence.
Gastric cancer is a major health problem, as it is the second leading cause of cancer death and the fourth most common cancer worldwide [ 24 ]. Surgery is a major curative strategy for gastric cancer [ 24 ]. However, there has been no consensus yet on how to deal with it. Our results were consistent with those of previous studies [ 8 , 21 , 25 ]. Theoretically, if PDs are completely closed, no PH can occur. However, similar to a previous study [ 14 ], one case of PH occurred after we began closing PDs.
We found that the PH patient underwent gastrectomy during the first week when we started to close PDs, and there have been no PH patients in the closure group since then. Both surgeons participating in the study were very well experienced with gastrectomy and far beyond their learning curve for this operation, but this was not necessarily the case for PD closure.
Therefore, the reason for this case of PH may be incomplete closure of the PD during primary surgery [ 26 ]. Another explanation is that defects may open after the loss of mesenteric fat, leading to the formation of PH [ 27 ]. Therefore, although the closure of all mesenteric defects cannot completely prevent PH, current studies have shown that it may decrease the incidence rate. To our knowledge, there has been no study that specifically investigated the rate of PH after gastrectomy for gastric cancer.
Several studies examining internal hernias after gastrectomy for gastric cancer have been conducted. The overall rate of internal hernia they were all PDs in this study was 1. The rate of internal hernia varied greatly among different studies. These differences may be caused by different inclusion groups, diagnostic criteria, follow-up periods, laparoscopy proportions, and mesenteric defect closures [ 1 ].
The rate of internal hernia in this study was lower than that in most previous studies. The possible reason is that we routinely closed the jejunojejunostomy mesenteric defects in all patients, and no internal hernia was found at these defects in this study; however, most authors left the defects open before they changed their technique to close all mesenteric defects, and many internal hernias were located at jejunojejunostomy mesenteric defects in their studies.
In a study conducted by Miyagaki et al. The 3-year incidence rate of internal hernia in their study was 0. In previous studies, laparoscopic surgery was found to be a risk factor for PH [ 1 , 7 , 14 , 21 , 28 ].
The possible reason was fewer adhesions [ 1 , 14 ]. However, similar to a previous study [ 8 ], laparoscopic surgery was not a risk factor for PH in the present study.
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