Counterclockwise rotation of Roux-en-Y limb significantly reduces internal herniation in laparoscopic Roux-en-Y gastric bypass (LRYGB).

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 (367 (82.7%) were females and 77 (17.3%) were males, two deaths excluded from the analysis) consecutive patients from our institutional bariatric database who underwent LRYGB. 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 jejunojejunostomy performed on the right side of the axis of the mesentery (group 1). In 151 patients, the Roux limb was constructed by a counterclockwise rotation of the Roux limb resulting in the jejunojejunostomy 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 were used for the analysis.
RESULTS: Of a total 442 (mean age, 43.7 ± 10.3 years; mean BMI pre-op was 46.4 ± 5.1; and 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 four (19%) were through the mesenteric defect. Group 1 patients had significantly higher overall internal hernias (20/291, 6.9% vs. 1/151, 0.7%; P = 0.0018) and Peterson's hernias (16/291, 5.5% vs. 1/151, 0.7%; P = 0.0089) compared with 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 and 3.4% vs. not closed, 13/325, 4%; P = 1.00). Within the group where Peterson's defect was closed, clockwise rotation and anastomosis on the right side of the axis of the mesentery was associated with significantly higher incidence of Peterson's hernias compared with counterclockwise rotation (4/54 vs. 0/63; P = 0.043). In the group where Peterson's defect was not closed, clockwise rotation was associated with higher incidence of internal hernias that did not reach statistical significance (12/237, 5.1% vs. 1/88, 1.1%; P = 0.12). This study demonstrates that the technique for construction of the Roux limb is a major factor in the development of internal hernias. Construction of the Roux limb with a counterclockwise rotation of the bowel, such that both jejunojejunostomy anastomosis and ligament of Treitz are to the left of the axis of the mesentery significantly reduces the incidence of internal hernias.