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Laparoscopic donor nephrectomy was introduced in 1995 as a means of minimally invasive surgeries that entail kidney extraction from healthy individuals. Since then, it has widely overtaken the traditional open surgical approaches, especially in live donor nephrectomy procedures worldwide. Laparoendoscopic single-site surgery is considered a more optimized surgical approach utilizing a single incision instead of four. Various studies have scrutinized many of the risk factors related to such surgeries, most commonly: vascular problems, intraoperative organ injury, and postoperative ileus. Other rare complications have not been thoroughly explored due to their decreased prevalence. Internal hernias are considered a rare complication of laparoendoscopic single-site surgery with dangerous repercussions ranging from bowel obstruction to ischemia, and necrosis. Our study presents a rare case of a trans-mesenteric internal hernia following laparoendoscopic single-site surgery. The patient was relatively healthy with no serious medical conditions. However, the past medical history did record a diagnosis of irritable bowel syndrome a few years back. Knowing that the occurrence of internal hernias is infrequent, we recommend that mesenteric defects be taken seriously to avoid the risk of internal hernias and their complications., (© 2024. The Author(s).)

Transmesenteric internal hernia is an uncommon cause of small bowel obstruction that occurs when small bowel loops protrude through a mesenteric defect into the abdominal cavity. Herein, we present an unexpected case of colonoscopy-induced transmesenteric internal hernia. An 81-year-old male patient presenting with intermittent hematochezia and constipation had undergone a laparoscopic left nephrectomy for ureteral cancer. A colonoscopy was performed to identify the etiology of his symptoms. He complained of severe abdominal pain 2 h after the examination despite uneventful endoscopic procedures, including cold snare polypectomy. Contrast-enhanced computed tomography revealed a strangulated small bowel obstruction with a closed-loop formation outside the descending colon. The small bowel loop was incarcerated into the left retroperitoneal space. Emergency laparotomy detected small bowel loops that prolapsed into the nephrectomy pedicle via a descending mesenteric defect, developed during the laparoscopic left nephrectomy. The incarcerated small bowel was detached from the hernia and returned to its normal position, and the mesenteric defect was closed. He demonstrated an uneventful postoperative course, with no internal hernia recurrence after discharge. This case indicates the risk of transmesenteric internal hernia through inadvertently created mesenteric defects should be borne in mind, especially when performing colonoscopies in patients who underwent laparoscopic nephrectomies., (© 2024. Japanese Society of Gastroenterology.)

Internal hernia through the Treitz fossa following robotic pancreatoduodenectomy is a rare but potentially serious complication. In our review of 328 cases of robotic pancreatoduodenectomies, two patients (0.6%) required repeat surgery due to internal herniation of the entire small bowel through the Treitz fossa. This complication can present as afferent loop syndrome, with symptoms including nausea, vomiting, and abdominal distension, possibly leading to cholangitis and pancreatitis. Timely diagnosis and intervention are paramount, as conservative management often fails. Preventive measures involve closing the peritoneal defect in the Treitz fossa at the end of robotic pancreatoduodenectomy, particularly in lean patients with thin mesentery who are at increased risk of internal hernia due to increased mobility of the small bowel. This technical note elucidates the pathogenesis of Treitz hernia following robotic pancreatoduodenectomy and underscores the importance of closing the peritoneal breach to prevent this rare yet potentially serious complication., (© 2024. Italian Society of Surgery (SIC).)

Introduction: Internal hernia (IH) after Roux-Y gastric bypass (RYGB) can lead to extended small bowel ischemia if it not recognized and treated promptly. The aim of this study is to show whether improvement in mesenteric defect (MD) closure reduces the incidence of IH., Patients and Methods: Retrospective analysis of prospectively collected data from our database including all patients who underwent laparoscopic RYGB between 1999 and 2015. The usual technique was a retrocolic/retrogastric RYGB. We divided patients in four groups according to the closure technique for MD and compared incidences of IH between groups. All patients had at least 8 years of follow-up., Results: A total of 1927 patients (1497 females/460 males, mean age of 41.5 ± 11 years) were operated. A retrocolic/retrogastric RYGB was performed in 1747 (90.7%) and an antecolic RYGB in 180 patients. Mean duration of follow-up was 15 (8-24) years. 111 patients (5.8%) developed IH, the majority through the jejunojejunostomy (JJ, 3.7%) and Petersen (1.7%) defects. With improvement of closure technique, the incidence decreased over time, from 12.9% in the group with separate sutures to 1.05% in the most recent group with running non-absorbable sutures and an additional purse-string at the JJ defect (p < 0.0001)., Conclusion: Meticulous closure of MD during RYGB is a very important step that significantly reduces the IH risk after RYGB, even with a retrocolic/retrogastric anatomy. Using running non absorbable braided sutures and an additional purse-string suture at the JJ is the most effective technique, but a small IH risk persists. A high index of suspicion remains necessary in patients who present with acute abdominal pain after RYGB., (© 2024. The Author(s).)

Internal herniation (IH) is a common problem after laparoscopic Roux-en-Y gastric bypass surgery (RYGB). Routine closure of the mesenteric defects (MDs) reduces the risk of IH. Only very few articles report on risk factors for IH or describe detailed closing techniques. There is no consensus yet on the best closing method. The objective of this study is to determine the optimal stapling method for closure of MDs after RYGB. All performed RYGB procedures in our high-volume bariatric institute were included. Quality of the closure was scored in the categories poor, sub-optimal, and optimal, to see if the quality of the closure would predict the chance of reopening of the MDs and, therefore, the chance of IH. During any type of laparoscopy in the follow-up of the patient, the conditions of the MDs were stated, for example during diagnostic laparoscopy in symptomatic patients suspicious for IH or during laparoscopic cholecystectomy. Technically well-executed closure of Petersen's space (PS) with two rows of staples had a greater chance of still being closed upon re-inspection compared to closure with one row (odds ratio = 8.1; 95% confidence interval [1.2-53.2], p = 0.029). Optimal closure of the MD at the jejuno-jejunostomy (JJ-space, JJS) resulted in more closed JJSs upon re-inspection compared to sub-optimal closure (odds ratio = 3.6 [CI 95% 0.8-16.1], p = 0.099). Non-optimally closed MDs had higher reopening rates and, therefore, pose an additional risk for IH. Our classification provides a quality assessment of MD closure during RYGB and gives insight into how to optimize surgical technique., (© 2024. The Author(s).)

Background: The preservation of the left colic artery (LCA) has emerged as a preferred approach in laparoscopic radical resection for rectal cancer. However, preserving the LCA while simultaneously dissecting the NO.253 lymph node can create a mesenteric defect between the inferior mesenteric artery (IMA), the LCA, and the inferior mesenteric vein (IMV). This defect could act as a potential "hernia ring," increasing the risk of developing an internal hernia after surgery. The objective of this study was to introduce a novel technique designed to mitigate the risk of internal hernia by filling mesenteric defects with autologous tissue., Methods: This new technique was performed on eighteen patients with rectal cancer between January 2022 and June 2022. First of all, dissected the lymphatic fatty tissue on the main trunk of IMA from its origin until the LCA and sigmoid artery (SA) or superior rectal artery (SRA) were exposed and then NO.253 lymph node was dissected between the IMA, LCA and IMV. Next, the SRA or SRA and IMV were sequentially ligated and cut off at an appropriate location away from the "hernia ring" to preserve the connective tissue between the "hernia ring" and retroperitoneum. Finally, after mobilization of distal sigmoid, on the lateral side of IMV, the descending colon was mobilized cephalad. Patients'preoperative baseline characteristics and intraoperative, postoperative complications were examined., Results: All patients' potential "hernia rings" were closed successfully with our new technique. The median operative time was 195 min, and the median intraoperative blood loss was 55 ml (interquartile range 30-90). The total harvested lymph nodes was 13.0(range12-19). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 8.0 days. One patient had an injury to marginal arterial arch, and after mobolization of splenic region, tension-free anastomosis was achieved. No other severe postoperative complications such as abdominal infection, anastomotic leakage, or bleeding were observed., Conclusions: This technique is both safe and effective for filling the mesenteric defect, potentially reducing the risk of internal hernia following laparoscopic NO.253 lymph node dissection and preservation of the left colic artery in rectal cancer surgeries., (© 2024. The Author(s).)

Abstract: Obesity remains a global health challenge linked to several comorbidities, such as obstructive sleep apnea, hypertension, hyperlipidemia, and diabetes. The prevalence of bariatric surgeries being performed is steadily increasing because it is a highly effective surgical tool used to achieve significant permanent weight loss. However, with all weight loss surgeries, several complications may not present for months to years after the initial procedure. In particular, the anatomical changes that occur after the Roux-en-Y gastric bypass (RNYGB) make the risk of internal hernias high. This particular complication is rare but lethal if unrecognized and not treated promptly. This clinical case study aims to provide readers with an overview of diagnosing and recognizing an internal hernia in the setting of previous laparoscopic RNYGB surgical history. Because of the sheer increase in the volume of patients undergoing bariatric surgery worldwide, health care providers must be well educated on the insidious presentations of this late complication and be prepared to act quickly to diagnose and treat these acute abdomen scenarios., Competing Interests: Competing interests: The author reports no conflicts of interest., (Copyright © 2024 American Association of Nurse Practitioners.)

Background: Postoperative internal hernias after Roux-en-Y gastric bypass (RYGB) have an incidence of 2%-9% and are a surgical emergency. Evidence on factors associated with length of stay (LOS) after emergent internal hernia reduction in RYGB patients is limited., Methods: This is a retrospective review of patients who underwent internal hernia reduction after RYGB at our tertiary care center over a 5 year period from 2015 to 2020. Demographics, comorbidities, and intra- and postoperative hospital course were collected. Univariate and multivariate linear regressions were used to investigate factors associated with LOS., Results: We identified 38 patients with internal hernia after RYGB. These patients with mean age 44.1 years were majority female (71.1%) and white race (60.5%). Of the 24 patients where the RYGB was done at our institution, the mean RYGB to IH interval was 43 months. Petersen's defect (57.8%) followed by jejuno-jejunal mesenteric defect (31.6%) were the most common locations for IH. Both Petersen's and jejuno-jejunal mesenteric hernias were found in 4 cases (10.5%). Revision of bypass and small bowel resection were required in 13.2% and 5.3% of cases, respectively. The median (interquartile range) length of stay (LOS) was 2 days. On the multivariate analysis, male sex ( P = .019), conversion to exploratory laparotomy ( P = .005), and resection of small bowel ( P < .001) were independent risk factors for increased LOS., Conclusion: The most common location of IH after RYGB is Petersen's defect, followed by jejuno-jejunal mesenteric defect. LOS was significantly associated with male sex, exploratory laparotomy, and resection of small bowel., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

72-year-old man who was diagnosed with transverse colon cancer cT3N1aM0, Stage Ⅲb, and underwent laparoscopic- assisted resection of the transverse colon. Postoperatively, the patient was discharged from the hospital after 24 days due to complications such as paralytic ileus and intra-abdominal abscess caused by prolonged intestinal congestion. On postoperative day 91, the patient developed abdominal pain and vomiting at home, and was rushed to our hospital on the same day. Abdominal CT showed that an internal hernia had formed in the mesenteric defect after resection of the transverse colon, which was suspected to have caused obstruction of the small intestine. After adequate preoperative decompression of the intestinal tract, a laparoscopic surgery was performed on the 9th day. The operative findings were that the jejunum(100- 160 cm from the Treitz ligament)had strayed into the mesenteric defect of the transverse colon, resulting in an internal hernia. After the internal hernia was repaired laparoscopically, the mesenteric defect was closed with a 3-0 V-Loc(non- absorbable). The patient had a good postoperative course and was discharged home 6 days after surgery.

Internal hernias, in particular, hernia of the foramen of Winslow, are rare and occur in typical sites. Laparotomy is common in these cases while laparoscopic surgery is rarely used in such urgent cases. However, modern diagnosis and treatment including computed tomography and laparoscopy allowing minimally invasive interventions are not an exception for patients with hernia of the foramen of Winslow. This approach is effective for this problem and prevents adverse outcomes of disease.

Internal hernia through an iatrogenic defect in the hepatic falciform ligament and acquired jejunal atresia in a 8-day-old neonate was reported. The PubMed, MEDLINE, CNKI, Wanfang and Weipu databases were searched The literature about the hepatic falciform ligament iatrogenic defect causing internal hernia was analysed. Ten other cases were collected from the world literature. Herniated intestinal necrosis was found in four cases. All cases were recovered uneventfully after operation. Internal herniation through an iatrogenic defect in the hepatic falciform ligament is extremely rare. However, the case reports are increasing, especially in the era of laparoscopic surgery. Adequate closure or open the defect is essential to prevent internal hernia occurrence., Competing Interests: None

Ovarian hyperstimulation syndrome (OHSS) is a serious complication of ovarian stimulation. Herein, we report a rare case of strangulated internal hernia in a woman with severe OHSS following ovulation induction. A delay in the diagnosis and management of acute abdominal pain can lead to serious problems. The aim of this case report was to highlight the diagnostic difficulties of abdominal pain in women with OHSS, and emphasize the positive effects of imaging and a timely differential diagnosis in clinical practice.

Objective: Petersen hernia is a rare but severe complication after gastrectomy, which has been reported by very few studies. This study is dedicated to summarize the clinical characteristics and management of Petersen hernia after gastrectomy in patients with gastric cancer in order to provide reference to clinical practice. Methods: A descriptive case-control study was carried out. All the qualified patients were screened from the database of digestive malignancies in Nanjing Drum Tower Hospital. The inclusion criteria were as follows: Petersen hernia confirmed during operation; previous gastrectomy history due to gastric cancer; complete clinical data. The clinical manifestation, perioperative data and follow-up outcome were summarized. Results: A total of 12 qualified patients were included. They were all male with a mean age of (65.3±8.5) years old, and whose clinical presentation had last for (6~143) hours (median: 21 hours). Common complaints included abdominal pain and bloating. All the patients were admitted to the emergency department. Preoperative CT showed dilatation and effusion of small intestine. Other imaging manifestations included whirlpool sign, target sign, mesenteric retraction or congestion and edema, abdominal and pelvic effusion, etc. Hematological examination showed white blood cell count, ratio of neutrophils, procalcitonin and C-reactive protein were higher than the normal range. The median interval to previous gastrectomy is 20.5 (0.5-55.0) months. The previous gastrectomy of 12 cases included 2 cases of laparoscopic surgery and 10 of laparotomies. Ten cases underwent emergency surgery immediately, and 2 cases underwent surgery after ineffective conservative treatment. Six cases received small bowel restoration without bowel resection, and the other 6 cases received small bowel resection with a mean length of 76 (11~300) cm. Six cases were transferred into ICU with a stay of (2.5±0.8) days. One case deceased at postoperative day 2, due to subtotal small bowel resection, and the other 11 cases survived without grade III or above complication according to Clavien-Dindo classification. The overall postoperative hospitalization was (9.2±3.6) days. During the postoperative follow-up, no acute gastrointestinal symptoms or acute abdomen recurred. Conclusions: Petersen hernia is more common in male, whose onset and progress are rapid and emergent, and prognosis is poor.

A 26-year-old multigravida, 30 +3 weeks pregnant woman, was referred to our tertiary referral centre with acute abdominal pain and vomiting suspected for internal herniation. She had a history of a primary banded Roux-en-Y gastric bypass (B-RYGB). The MRI scan showed a clustered small bowel package with possible mesenteric swirl diagnosed as internal herniation. A diagnostic laparoscopy was converted to laparotomy showing an internal herniation of the alimentary limb through the silicone ring. The internal herniation was reduced by cutting the silicone ring. Postoperative recovery, remaining pregnancy and labour were uneventful. During pregnancy after B-RYGB, small bowel obstruction can in rare cases occur due to internal herniation through the silicone ring. Education regarding this complication should be provided before bariatric surgery. Treatment of women, 24 to 32 weeks pregnant, in a specialised centre for bariatric complications with a neonatal intensive care unit is advised to improve maternal and neonatal outcome., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The common complications of radical hysterectomy and pelvic lymphadenectomy usually include wound infection, hemorrhage or hematomas, lymphocele, uretheral injury, ileus and incisional hernias. However, internal hernia secondary to the orifice associated with the uncovered vessels after pelvic lymphadenectomy is very rare., Case Presentation: We report a case of internal hernia with intestinal perforation beneath the superior vesical artery that occurred one month after laparoscopic pelvic lymphadenectomy for cervical cancer. A partial ileum resection was performed and the right superior vesical artery was transected to prevent recurrence of the internal hernia., Conclusions: Retroperitonealization after the pelvic lymphadenectomy should be considered in patients with tortuous, elongated arteries which could be causal lesions of an internal hernia.

Internal hernia (IH) represents a delayed complication of the laparoscopic Roux-en-Y gastric bypass (LRYGB) and it is historically difficult to identify preoperatively. Numerous CT signs were considered suggestive of IH but none of them is pathognomonic. In this study, we aim to evaluate the accuracy of CT in diagnosing IH, differentiating from non-specific abdominal pain. This can lead to a way of personalized medicine and improve the outcome of anti-obesity treatments. We retrospectively reviewed CT scans of 50 patients previously subjected to LRYGB procedure, with a clinical suspicion of IH. 3 groups of patients were identified: IH group (21 patients with a surgical confirmed IH), negative group (12 patients in whom IH was not confirmed at surgery), and control group (17 patients who were not surgically explored because of low/no suspicion of IH). We divided CT signs into three groups: "bowel loop signs", "vessel signs", and "venous congestion/stasis signs". The accuracy of CT in detecting IH was tested by comparing each sign, either individually or in combination, with the surgical findings. Statistical analysis showed that "vessel signs" (swirl sign, superior mesenteric vein beaking, mesenteric arteries, and veins branches inversion) present the highest distribution in patients with IH demonstrated at surgery, with a higher accuracy in case of simultaneous presence of two or three signs. CT imaging is highly accurate in diagnosing IH. Despite no single sign being pathognomonic, the combination of two or more signs, especially among the "vessels signs", can suggest the IH, even in pauci-symptomatic patients.

Internal hernia beneath the vascular structures after pelvic lymphadenectomy is a rare condition. Herein, we report a case of a strangulated internal hernia beneath the obturator nerve 38 months after laparoscopic radical cystectomy with extended pelvic lymphadenectomy. Computed tomography revealed dilated small bowels and a closed loop in the pelvis. The emergency laparotomy was performed, and a strangulated internal hernia beneath the obturator nerve was observed. It is necessary to consider the possibility of internal hernia beneath the vascular structure, including the obturator nerve, after the pelvic lymph lymphadenectomy, particularly via a minimally invasive approach., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Duplication of inferior vena cava (DIVC) is a rare congenital malformation of extreme importance for vascular and urology surgeons, interventional radiologists. Oftentimes it goes unnoticed and is diagnosed incidentally at a routine or emergency CT-scan when complications occur due to associated congenital malformations. We present a case of a 70-year-old male patient who was admitted into the emergency room (ER) accusing abdominal pain. He was diagnosed with an intestinal obstruction due to a left paraduodenal hernia (LPDH), associated with a DIVC. The reviewing the literature led to concluding that DIVC is not the cause of LPDH., (Celsius.)

Purpose: Internal hernia (IH) after laparoscopic left-sided colorectal resection (small bowel herniating underneath the neo-descending colon) can be a potentially devastating complication, resulting in acute small bowel obstruction or ischemia. IH has been described as a rare occurrence in a few retrospective case series; however, patients undergoing laparoscopic resection seem to be more prone to this complication. We assessed the prevalence of IH in a large cohort of patients who had undergone laparoscopic left-sided colorectal resection for colon or rectal cancer (CRC)., Methods: A database of consecutive patients at a single institution from 2012 to 2017 was reviewed. Postoperative abdominal computed tomography (CT) scans performed for routine cancer follow-up between 3 and 36 months after surgery were assessed retrospectively., Results: During the study period, 276 patients had undergone anterior resection for CRC, with 206 (75%) having been performed laparoscopically. A total of 198 eligible patients were identified, and a follow-up CT scan was available in 105 (53%) of these patients (median time to CT 10 months, range 3-34). Only one of the 198 (0.5%) patients presented with an acute small bowel obstruction secondary to an IH during follow-up. However, the prevalence of asymptomatic IH was noted to be much higher in the postoperative CT scans occurring in 22 of 105 (21%) patients., Conclusion: Asymptomatic IH after laparoscopic left-sided colorectal resection is common. Given the potential risk of acute small bowel obstruction and ischemia, routine closure of the mesenteric defect should be considered.

Introduction: We propose a novel technique to close Petersen's defect using barbed sutures and evaluate the safety and usefulness of this technique by assessing postoperative complications and measuring the time required to close Petersen's defect., Materials and Surgical Technique: Petersen's defect was closed laparoscopically with running non-absorbable barbed sutures (V-loc®) after a nodal dissection and reconstruction procedure. First, the transverse colon was elevated cranially, making the dorsal side of the transverse mesocolon a flattened surface. The intersection of the transverse mesocolon and Roux limb mesentery was then identified, and closure was started from this point. We continued to sew the transverse mesocolon and Roux limb mesentery toward the transverse colon with a running suture. At the end of suturing, we placed one or two stitches in the fatty appendices of the transverse colon and cut the free tail of thread as short as possible., Discussion: We investigated postoperative complications and measured the time required to close Petersen's defect in 64 patients who underwent this technique. The results showed that this closure technique could be performed promptly and safely regardless of the patient, surgical procedure, and the experience of the operator., (© 2019 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)