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胃切除术后腹内疝病人临床特征及诊疗策略：一项多中心回顾性研究
谭雨翱, 吴振洋, 吴阿豪, 朱凯宁, 李正荣
中国实用外科杂志 ›› 2026, Vol. 46 ›› Issue (9) : 1253-1258.
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胃切除术后腹内疝病人临床特征及诊疗策略：一项多中心回顾性研究
Clinical characteristics, diagnosis, and treatment of postgastrectomy internal hernia: a multicenter retrospective study
目的 探讨胃切除术后腹内疝（PIH）的临床特征、诊疗要点及预防策略，为规范临床诊疗提供参考。方法 回顾性分析2020年1月至2025年12月南昌市第一医院、抚州市第一人民医院、南昌大学第一附属医院、上饶市人民医院4家医疗中心收治的117例PIH病人的临床资料，总结其临床特征、诊疗情况及预后。结果 病人以老年、消瘦男性为主，中位年龄为67岁，≥60岁者占73.50%，消瘦者占39.32%。既往手术以腹腔镜远端胃切除术为主，消化道重建以Billroth Ⅱ式最常见；疝类型以Petersen裂孔疝为主（81.20%），半数以上病人于术后3年内发病。既往手术中闭合系膜间隙者仅占38.46%。病人多表现为突发剧烈腹痛，腹部增强CT是首选诊断方法，典型征象检出率为94.87%。所有病人均接受手术治疗，以急诊开放手术为主；17.09%的病人接受肠切除吻合术。术后并发症发生率为15.38%，病死率为1.71%。首次手术闭合系膜间隙可减少二次手术时肠切除的发生率。结论 PIH起病急、进展快，本组病例以老年、消瘦男性及既往接受Billroth Ⅱ式重建的腹腔镜胃切除术病人居多。腹部增强CT有助于早期诊断，及时手术是改善预后的关键；胃切除术中应常规闭合系膜间隙，以预防PIH并减少二次手术时肠切除的发生率。
Objective To explore the clinical characteristics, key aspects of diagnosis and treatment, and preventive strategies for postgastrectomy internal hernia (PIH), providing a reference for standardized clinical diagnosis and treatment. Methods A retrospective analysis was conducted on the clinical data of 117 patients with PIH admitted to four medical centers, namely the First Hospital of Nanchang, the First People’s Hospital Fuzhou, the First Affiliated Hospital of Nanchang University and Shangrao People’s Hospital, from January 2020 to December 2025, to summarize their clinical characteristics, diagnosis and treatment, and prognosis. Results Most patients were elderly, emaciated men, with a median age of 67 years; 73.50% were aged ≥60 years, and 39.32% were emaciated. Laparoscopic distal gastrectomy was the predominant prior operation, and Billroth Ⅱ reconstruction was the most common gastrointestinal reconstruction procedure. Petersen’s hernia was the predominant type (81.20%), and more than half of the patients developed PIH within 3 years after gastrectomy. Mesenteric defects had been closed during the index gastrectomy in only 38.46% of patients. Sudden, severe abdominal pain was the main presenting symptom. Contrast-enhanced abdominal CT was the first-line diagnostic modality, with a detection rate of 94.87% for typical signs. All patients underwent surgery, predominantly emergency open surgery; 17.09% required bowel resection and anastomosis. The postoperative complication rate was 15.38%, and the mortality rate was 1.71%. Closure of mesenteric defects during the initial operation reduced the incidence of bowel resection during reoperation. Conclusion PIH has an acute onset and rapid progression. In this cohort, PIH was predominantly seen in elderly, emaciated men who had previously undergone laparoscopic gastrectomy with Billroth Ⅱ reconstruction. Contrast-enhanced abdominal CT facilitates early diagnosis, and timely surgery is critical for improving prognosis. Routine closure of mesenteric defects during gastrectomy is recommended to prevent PIH and lower the rate of bowel resection during reoperation.
gastrectomy / internal hernia / clinical characteristics / diagnosis / surgical treatment
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中国抗癌协会胃癌专业委员会. 胃癌手术预康复管理中国专家共识(2024版)[J]. 中国实用外科杂志, 2024, 44(10):1081-1089. DOI:10.19538/j.cjps.issn1005-2208.2024.10.01.
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Internal herniation (IH) is the most common complication after Roux-en-Y gastric bypass surgery (RYGB). Although primary closure has reduced the incidence, recurrences are a continued problem. This study aimed to investigate long-term follow-up and recurrence risk of IH surgery.A retrospective cohort study of laparoscopic RYGB operated patients operated for a first IH between April 2012 and April 2015 at Skåne University Hospital in Malmö, Sweden. Status of primary closure of mesenteric gaps, time since RYGB, and findings at IH surgery were retrieved from medical records. Follow-up until December 31st, 2019, included recurrences of IH, number of computed tomography (CT) scans, emergency visits, readmissions, and other acute surgeries.IH (n = 44) occurred almost equally in Petersen's space (n = 24) and beneath the jejunojejunostomy (n = 20). Long-term follow-up (median 75 months) of 43 patients registered an IH recurrence rate of 14% (n = 6). All recurrences occurred in the other mesenteric gap. One patient suffered a third IH, and one patient had four IH events. During follow-up, 56% (n = 24) had ER visits for abdominal pain, 47% (n = 20) had ≥ 1 abdominal CT scan, and 40% (n = 17) were readmitted. A third of readmitted (6/17) patients suffered a recurrence of internal herniation. Two other patients were readmitted ≥ 10 times for chronic abdominal pain.Surgery for IH had a low risk of recurrence at the treated mesenteric gap, but a 14% recurrence risk at the other mesenteric gap, emphasizing the importance of carefully investigating weaknesses or gaps at the other mesenteric defect during surgery for IH.© 2023. The Author(s).
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Internal herniation (IH) can be a life-threatening complication of Roux-en-Y gastric bypass (RYGB). Randomised controlled trials support the routine closure of mesenteric spaces at RYGB. However, there is currently no consensus on the method of closure in clinical practice. The purpose of this survey is to understand bariatric surgeons' practice in this regard.We conducted an international survey, whereby questions were created through collaboration of a consensus group of bariatric surgeons and hosted on the SurveyMonkey platform. The survey was distributed among British Obesity and Metabolic Surgery Society (BOMSS) members and international professional channels including The Upper Gastrointestinal Society (TUGS) and social media.One hundred and thirty-six surgeons from 34 countries completed the survey. Of these, 49 respondents were UK-based surgeons with a cumulative experience of approximately 2500 RYGB per annum. Forty-five (91.8%) respondents reported always closing mesenteric defects, of whom 57.8% elected to use non-absorbable non-barbed sutures, followed by staples/clips in 28.9% and a selection of other methods. Most respondents used more than one method. A total of 2 UK and 14 non-UK participants reported never closing mesenteric spaces.This survey has shown heterogeneity among defect closure and no consensus on preferred type. Additionally, there remains a practice of non-closure of mesenteric defects. We hope these findings help to inform further needed research and consensus building among experts.© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.
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Short-term and midterm data suggest that mesenteric defects closure during laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery reduces the risk of internal herniation with small bowel obstruction (SBO) but may increase risk of kinking of the jejunojejunostomy in the early postoperative period. However, to our knowledge, there are no clinical trials reporting long-term results from this intervention in terms of risk for SBO or opioid use.To evaluate long-term safety and efficacy outcomes of closure of mesenteric defects during LRYGB.This randomized clinical trial with a 2-arm, parallel, open-label design included patients with severe obesity scheduled for LRYGB bariatric surgery at 12 centers in Sweden from May 1, 2010, through November 14, 2011, with 10 years of follow-up after the intervention.During the operation, patients were randomly assigned 1:1 to closure of mesenteric defects beneath the jejunojejunostomy and at the Petersen space using nonabsorbable running sutures during LRYGB or to nonclosure.The primary outcome was reoperation for SBO. New incident, chronic opioid use was a secondary end point as a measure of harm.A total of 2507 patients (mean [SD] age, 41.7 [10.7] years; 1863 female [74.3%]) were randomly assigned to closure of mesenteric defects (n = 1259) or nonclosure (n = 1248). After censoring for death and emigration, 1193 patients in the closure group (94.8%) and 1198 in the nonclosure group (96.0%) were followed up until the study closed. Over a median follow-up of 10 years (IQR, 10.0-10.0 years), a reoperation for SBO from day 31 to 10 years after surgery was performed in 185 patients with nonclosure (10-year cumulative incidence, 14.9%; 95% CI, 13.0%-16.9%) and in 98 patients with closure (10-year cumulative incidence, 7.8%; 95% CI, 6.4%-9.4%) (subhazard ratio [SHR], 0.42; 95% CI, 0.32-0.55). New incident chronic opioid use was seen among 175 of 863 opioid-naive patients with nonclosure (10-year cumulative incidence, 20.4%; 95% CI, 17.7%-23.0%) and 166 of 895 opioid-naive patients with closure (10-year cumulative incidence, 18.7%; 95% CI, 16.2%-21.3%) (SHR, 0.90; 95% CI, 0.73-1.11).This randomized clinical trial found long-term reduced risk of SBO after mesenteric defects closure in LRYGB. The findings suggest that routine use of this procedure during LRYGB should be considered.ClinicalTrials.gov Identifier: NCT01137201.
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余江, 李国新. 腹腔镜胃癌根治术关键技术标准及评价[J]. 中国实用外科杂志, 2024, 44(1):61-65.DOI:10.19538/j.cjps.issn1005-2208.2024.01.09.
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The incidence and clinical presentation of internal hernia after gastrectomy have been changing in the minimally invasive surgery era. This study aimed to analyze the clinical features and risk factors for internal hernia after gastrectomy for gastric cancer.We retrospectively analyzed internal hernia after gastrectomy for gastric cancer in 6474 patients between January 2003 and December 2016 at Seoul National University Bundang Hospital. Multivariable logistic regression was performed to evaluate risk factors.Internal hernias identified by computed tomography or surgical exploration were 111/6474 (1.7%) and the median interval time was 450 days after gastrectomy. Fourteen (0.9%) of the 1510 patients who underwent open gastrectomy and 97 (2.0%) of the 4964 patients who underwent laparoscopic gastrectomy developed internal hernia. Of the 6474 patients, internal hernia developed in 0 (0%), 9 (1.1%), 40 (3.1%), 56 (3.3%), 6 (2.3%), and 0 (0%) patients who underwent Billroth I, Billroth II, Roux-en-Y, uncut Roux-en-Y, double tract, and esophagogastrostomy reconstructions, respectively. Fifty-nine (53.2%) of 111 patients with symptomatic hernia underwent surgery. Of the 59 internal hernias, treated surgically, 32 (53.2%), 27 (45.8%), and 0 (0%) were identified in jejunojejunostomy mesenteric, Petersen's, and transverse colon mesenteric defects, respectively. In multivariate analysis, non-closure of mesenteric defects (P < 0.01), laparoscopic approach (P < 0.01), and totally laparoscopic approach (P = 0.03) were independent risk factors for internal hernia.The potential spaces such as Petersen's, jejunojejunostomy mesenteric, and transverse colon mesenteric defects should be closed to prevent internal hernia after gastrectomy for gastric cancer.
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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.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.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).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).
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张琪, 余文豪, 周家杰, 等. 胃癌根治术后内疝致小肠梗阻15例临床诊治分析[J]. 中国实用外科杂志, 2023, 43(4):429-432.DOI:10.19538/j.cjps.issn1005-2208.2023.04.13.
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A well-known complication of laparoscopic Roux-en-Y gastric bypass surgery (LRYGB) is bowel obstruction due to internal herniation (IH). Evidence suggests that mesenteric defects should be closed during LRYGB to reduce the risk of IH. Therefore, surgeons are now closing mesenteric defects during LRYGB using sutures, clips, or fibrin glue. However, it has been reported that complications may arise due to the closure of mesenteric defects. The aim of this review was to summarize the reported possible complications associated with the closure of mesenteric defects during LRYGB.A literature search of PubMed and EMBASE was performed to identify studies related to the closure of mesenteric defects during LRYGB. The studies were screened for the listing of possible complications associated with the closure of mesenteric defects. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations.Thirty studies complied with the inclusion criteria for our analysis, which included 21,789 patients. Reported complications related to closure of the mesenteric defects were: small bowel obstruction because of IH, kinking, and adhesions. IH occurred because of incomplete closure of the mesenteric defects in 1.4% of all patients, 1.2% by the antecolic approach, and 1.9% by the retrocolic approach, respectively. Kinking of the small bowel occurred in.2% of 1630 patients after closure of the mesenteric defects with clips and adhesion formation was found among 4.6% of 152 patients after closure of the mesenteric defects with nonabsorbable sutures.The reported risk of complications caused by closure of the mesenteric defects during LRYGB seems low.Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
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The aim of this study was to clarify internal hernia (IH) characteristics after laparoscopic gastrectomy.This was a retrospective study of 1943 consecutive gastric cancer patients who underwent surgery at our institute between 2004 and 2015. Since 2013, our technique includes antecolic Roux-en-Y (RY) with closure of all mesenteric defects during laparoscopic total gastrectomy (LTG) as standard.Postoperative IH was only detected in patients who underwent total gastrectomy with RY reconstruction. Furthermore, the incidence of IH was significantly higher after LTG than after open total gastrectomy (4.9% vs. 1.0%; P=0.005). IH after LTG occurred in 8.0% of patients before standardization with closure of the mesenteric defects, but no IH was observed after standardization (P=0.047).Closure of all mesenteric defects is recommended for gastric cancer patients who undergo LTG with antecolic RY. Registration number: UMIN000009163/000025029 (www.umin.ac.jp/ctr/).
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Laparoscopic gastrectomy (LG) is increasingly used to treat gastric cancer. Simultaneously, internal hernia (IH) has been reported after LG with Roux-en-Y reconstruction (RY). The aim of this study was to investigate IH after LG with RY for gastric cancer.This study included 15 patients with IH from a database of 355 consecutive patients who underwent LG with RY for gastric cancers. We retrospectively analyzed IH incidence and clinical characteristics by operative procedures.The total incidence of IH was 4.2%. The incidence of IH at Petersen's defect tended to decrease with modifications to the reconstruction methods, but not significantly so. The incidence of IH at jejunojejunostomy mesenteric defect significantly decreased with closure of this defect (p = 0.01). The incidence of IH at transverse mesocolic defect was 1.3% in patients who underwent retrocolic RY; emergent small-bowel resection was only required in two cases of herniation through this defect after laparoscopic total gastrectomy.Retrocolic RY with appropriate closure of defects can reduce IH incidence at Petersen's defect and at jejunojejunostomy mesenteric defect. Although the IH incidence at the transverse mesocolic defect is not particularly high, the possibility of herniation through this defect should be kept in mind.Copyright © 2017. Published by Elsevier Taiwan.
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Previously it has reported that the incidence of internal hernia can be decreased by closing Petersen's defect, but the perfect closure method, in fact, has not been discovered yet. In this study we have developed an easy and reliable method for closing Petersen's defect in the Roux-en-Y reconstruction after a laparoscopic distal gastrectomy.We performed intracorporeal Roux-en-Y reconstruction after laparoscopic distal gastrectomy with antiperistaltic gastrojejunostomy. The greater omentum is placed on the cranial side of the transverse colon through the defect between the elevated jejunum and the transverse mesocolon. Anastomosis is performed of the transverse mesocolon attached to the transverse colon, the greater omentum is passed through the Petersen's defect, and the stump of the mesojejunum is attached to the elevated jejunum by an interrupted suture. Petersen's defect is spread and straightened to stabilize the visual field. The thread is inserted first at the base of the stump of the elevated mesojejunum, next to the greater omentum, which has passed through Petersen's defect, and then to the transverse mesocolon to set the starting point of continuous suture. The stitches of continuous suture are sewn toward the transverse colon. Petersen's defect is closed completely.We performed this technique in 37 patients. All procedures were completed without intraoperative complication or conversion to laparotomy. During the follow-up period, none of the patients developed complications related to the internal hernia, such as Petersen's hernia.We have indicated a novel, easy, and secure closure procedure of Petersen's defect following laparoscopic distal gastrectomy with Roux-en-Y reconstruction.
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中华医学会外科学分会腹腔镜与内镜外科学组, 中国研究型医院学会机器人与腹腔镜外科专业委员会, 中国抗癌协会腔镜与机器人外科分会, 等. 腹腔镜胃癌手术操作指南(2023版)[J]. 中国实用外科杂志, 2023, 43(4):361-370. DOI:10.19538/j.cjps.issn1005-2208.2023.04.01.
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Obesity is a complex chronic disease with a rising global prevalence and significant health implications. The laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most widely performed bariatric procedures worldwide, ensuring significant weight loss and reducing obesity-related comorbidities. However, the risk of postoperative complications remains considerable. Multidetector computed tomography (MDCT) is regarded as the primary imaging modality for the assessment of suspected complications, due to its high diagnostic accuracy. This review offers a comprehensive overview of early (≤ 30 days) and late (> 30 days) postoperative complications, including anastomotic leak, abscess, hemorrhage, small bowel obstruction (SBO), internal hernia, gastro-gastric fistula, intussusception, and marginal ulcer, with emphasis on characteristic MDCT features. Due to its advantage as a dynamic method, upper gastrointestinal (Gl) studies with oral contrast material may be helpful for the diagnosis of leak and gastro-gastric fistula formation. A comprehensive understanding of the altered postoperative anatomy and the specific radiological signs of complications are essential for accurate MDCT interpretation, minimizing diagnostic errors and enabling timely, targeted clinical intervention. Today, MRI can be considered a problem-solver through its possibility of combining static with dynamic sequences in selected cases. In this narrative review, we highlight the most frequent complications of Roux-en-Y gastric bypass (LRYGB), allowing radiologists to become familiar with the typical radiological features and pitfalls in MDCT, upper GI studies, and MRI, when facing this type of surgery.
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