Background

A 61 year-old woman, who had undergone a Roux-en-y gastric bypass 8 years prior, presented with 4 years of intermittent right upper quadrant pain. She had a past medical history of hypertension, hyperlipidemia, and a past surgical history of a transvaginal hysterectomy, and the Roux-en-y gastric bypass. She had several ED visits for this. Her work up - which included an upper GI, ultrasound, CT abdomen and pelvis, and HIDA scans - was normal except an ultrasound showing mild gallbladder wall thickening with sludge. The decision was made to do an elective laparoscopic cholecystectomy, and ports were placed in the standard fashion. The gallbladder was inflamed, and a laparoscopic cholecystectomy was performed without incident. Chylous ascites, however, was also noted throughout the abdomen, which prompted evaluation of the bypass anatomy. The small intestine was run from the Roux limb to the JJ anastomosis as well as from the terminal ileum to the JJ. The JJ was found to be internally herniated through Pseudo-Petersen's space. This was reduced and the space was closed. An upper endoscopy was performed revealing a normal GE junction and GJ anastomosis without signs of esophagitis or ulcers. The patient tolerated the procedure well, went home the same day, and was symptom free at the postoperative visit. In conclusion, it is important for the general surgeon to understand gastric bypass anatomy so that they can appropriately address an incidentally found internal hernia for the treatment of pain in patients with a prior gastric bypass.