Background

Development of an internal hernia is a rare, but serious, complication after Roux-en-Y gastric bypass surgery. In this video, we present the case of a 71 year old male with a history of Roux-en-Y gastric bypass 15 years ago and recent perforated marginal ulcer requiring Graham patch repair. The patient presented to the emergency department with three days of epigastric abdominal pain. Given the patient's recent perforated marginal ulcer repair, he was initially managed with a proton pump inhibitor, sucralfate, pain medication, and an NPO diet. However, a subsequent computed tomography scan showed findings suggestive of internal hernia and he was taken emergently to the operating room for a diagnostic laparoscopy. Upon entry into the abdomen, a giant retro-Roux hernia was visible, along with congested mesentery and loops of ischemic bowel. The hernia was reduced laparoscopically, and the bowel was returned to its proper position. The hernia defect was closed with a non-absorbable suture. The patient recovered well and one month after follow-up was tolerating a regular diet.This video offers several important learning points. The first is the lifelong risk of internal hernias that accompany Roux-en-Y gastric bypass. The second is the difficulty of diagnosing internal hernias, particularly in patients with other abdominal pathology, as seen in this patient. Finally, given the patient's recent Graham patch repair, it brings into question if it should be routine to evaluate potential hernia defects during other abdominal surgeries for gastric bypass patients.