Life-threatening Petersen's hernia following open Beger's procedure.

Petersen's hernia (an internal hernia between the transverse mesocolon and Roux limb following Roux-en-Y reconstruction) is well described following laparoscopic gastric bypass surgery. We describe a Petersen-type hernia in a patient who had undergone complex open upper gastrointestinal surgery for chronic pancreatitis. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.

INTRODUCTION

Petersen's hernia is a rare complication of open surgery and has not been previously described following Beger's procedure for chronic pancreatitis.

CASE REPORT

A 72-year-old male presented as an emergency with sudden onset of central and lower abdominal pain, nausea and vomiting. He had a past surgical history of open Beger's procedure (duodenum preserving resection of the pancreatic head) performed 5 years ago for chronic pancreatitis. There were no other significant co-morbidities.

Computed tomography (Fig. 1) demonstrated a closed loop small bowel obstruction involving almost all of the jejunal loops with mesenteric venous congestion suggesting impending ischaemia. The transition point was posterior to the Roux loop.

Figure 1:

(a and b) Axial and coronal CT images showing obstruction of small bowel with transition point within Petersen's space (arrow).

He underwent emergency laparotomy. At surgery, a type C Petersen's hernia containing 245 cm of infarcted small bowel was encountered. This was resected and a double-barrelled jejuno-ileostomy was fashioned.

The patient was admitted to the intensive care unit for 48 h before being stepped down to a surgical ward. The patient was commenced on total parenteral nutrition in view of his proximal jejunostomy.

The patient had a prolonged in-patient stay of 11 weeks with a high-output stoma but did not require a return to theatre. He was discharged with home parenteral nutrition.

Two months later, he underwent uncomplicated reversal of double-barrelled jejuno-ileostomy and his parenteral nutrition was stopped. His recovery was uneventful and he was discharged 3 days later.

DISCUSSION

Petersen's hernia was first described in 1900 by Dr Petersen where an efferent loop of bowel herniates posterior to the gastrojejunal anastomosis through a space bounded by transverse mesocolon and Roux limb mesentery [1]. Petersen's hernia is an increasingly recognized complication of laparoscopic Roux-en-Y gastric bypass for morbid obesity. It is thought to arise because of a lack of internal adhesions after laparoscopic surgery combined with the significant loss of fat from the small bowel and colonic mesenteries. Three types of Petersen's hernia have been described: Type A involves the alimentary (Roux) limb, Type B involves the bilio-pancreatic limb and Type C involves the common channel [2]. PH can present non-specifically and progress rapidly to bowel infarction, peritonitis and death. Imaging can be inconclusive and clinical awareness with early intervention is important [3].

We are unaware of reports describing Petersen's hernia after Beger's procedure. Beger's procedure is a duodenum preserving resection of the pancreatic head. It is used in refractory chronic pancreatitis when medical therapy fails or when there is a suspicion of malignancy [4]. It involves resection of the pancreatic head whilst preserving the duodenum with a Roux-en-Y reconstruction between the pancreas and jejunum [5].

Petersen's hernia can occur in both laparoscopic and open surgery involving Roux-en-Y reconstruction. It can present as an emergency with bowel obstruction. Clinicians should have a high index of suspicion when assessing patients with previous operations involving Roux-en-Y reconstruction.

CONFLICT OF INTEREST STATEMENT

None declared.