Petersen's space hernia - An expanding diagnosis after bariatric surgery: A case report and review of literature

Royson Dsouza; Vijay Abraham; S Suraj

doi:10.4103/cmi.cmi_44_19

CASE REPORT

Year : 2020 | Volume : 18 | Issue : 1 | Page : 59-61

Petersen's space hernia - An expanding diagnosis after bariatric surgery: A case report and review of literature

Royson Dsouza, Vijay Abraham, S Suraj
Division of Surgery, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission	16-Oct-2019
Date of Decision	26-Nov-2019
Date of Acceptance	28-Nov-2019
Date of Web Publication	03-Feb-2020

Correspondence Address:
Dr. Vijay Abraham
General Surgery Unit 3, Christian Medical College Hospital, Vellore, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cmi.cmi_44_19

Abstract

Petersen's hernia refers to an internal herniation of small bowel through the potential space between the transverse mesocolon and the Roux limb of gastrojejunal anastomosis. The incidence of this is increasing with the widespread practice of bariatric surgery in the last decade. In this report, we present the case of a 44-year-old male who had undergone a laparoscopic Roux-en-Y gastric bypass for morbid obesity and presented after 14 months with a history of nonspecific abdominal pain. The examination of his abdomen was unremarkable. The computed tomography scan revealed the suspicious features of internal herniation of the small bowel and a twist in the mesentery. On diagnostic laparoscopy, he was found to have Petersen's space hernia. His clinical presentation, investigations, and treatment have been highlighted in this case report with a review of the literature. Although rare, Petersen's hernia could lead to a disastrous complication of small bowel strangulation if not intervened early. Hence, if suspected, the threshold to perform a diagnostic laparoscopy should be low.

Keywords: Bariatric surgery, internal hernia, minimally invasive surgery, Petersen's space hernia

How to cite this article:
Dsouza R, Abraham V, Suraj S. Petersen's space hernia - An expanding diagnosis after bariatric surgery: A case report and review of literature. Curr Med Issues 2020;18:59-61

How to cite this URL:
Dsouza R, Abraham V, Suraj S. Petersen's space hernia - An expanding diagnosis after bariatric surgery: A case report and review of literature. Curr Med Issues [serial online] 2020 [cited 2023 Jun 7];18:59-61. Available from: https://www.cmijournal.org/text.asp?2020/18/1/59/277523

Introduction

Laparoscopic Roux-en-Y gastric bypass (RYGB) has been shown to be a safe and effective alternative to traditional open RYGB. Although minimally invasive surgery has a significant reduction in postoperative adhesions, it is also associated with a higher risk of internal hernias.^[1] Petersen's hernia is a type of internal hernia that results from the passage of small bowel through the potential space between the transverse mesocolon and Roux limb of jejunum while creating gastrojejunal anastomosis. This complication was once very rare, and there were only about 178 cases reported until 1974.^[2] However, the incidence has increased in the last few years with the exponential growth in laparoscopic gastric bypass for the treatment of obesity.^{[3],[4],[5],[6]}

The diagnosis of Petersen's space hernia is very challenging as the patients can present many months or years after the procedure, and the symptoms are seldom specific.^[7] The clinical findings and imaging characteristics could also be misleading.^[8] In this case report, we present the case of a 44-year-old male who came 14 months after laparoscopic RYGB with nonspecific abdominal complaints and was subsequently diagnosed with Petersen's hernia. His clinical presentation, evaluation, and treatment have been outlined with a review of the literature.

Consent was obtained from the patient for his case to be reported.

Case Report

A 44-year-old male presented to the bariatric surgery unit with complaints of crampy abdominal pain for 3-week duration. It was associated with nausea but without any vomiting, abdominal distention, constipation, or obstipation. He had undergone a laparoscopic RYGB 14 months before this presentation. In the index surgery, a retrocolic posterior Roux-en-Y gastrojejunostomy was done, and the Petersen's defect was closed using nonabsorbable intracorporeal sutures. His body mass index was 38 kg/m² which had reduced to 26 kg/m² after the operation. On examination, he was comfortable without any apparent distress. His vitals were within the normal limits. His abdomen was soft and nontender. There was no distention, palpable mass, or organomegaly. The hernial sites were normal, and the rectal examination was unremarkable.

His baseline blood investigations were within the normal limits. A contrast computed tomography (CT) of the thorax and abdomen was done for further evaluation which revealed a significant reduction in the mesenteric fat with the suggestion of herniated small bowel loops above the transverse colon, with whirling and fat stranding of the mesentery [Figure 1].

Figure 1: Contrast computed tomography of the abdomen showing “whirl” sign (green arrowhead) and displacement of the small bowel above the level of the transverse colon (red arrowhead)

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In view of suspicion of an internal hernia, he was posted for a diagnostic laparoscopy. Intraoperatively, there was small bowel herniation through the defect in the superior aspect of the Petersen's space [Figure 2]. There were no features of small bowel obstruction or strangulation. The defect was closed after reducing the herniated bowel with a nonabsorbable suture. His postoperative recovery was rapid and uneventful. On follow-up after 8 months, he was asymptomatic and doing well.

Figure 2: Intraoperative image showing herniation of the small bowel through Petersen's space

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Discussion

The transverse mesocolon acts as a natural barrier between the stomach and the small intestine and by creating an infracolic compartment. This is disrupted by any gastrojejunal anastomosis (loop or Roux) creating a potential space for herniation.^[9] Petersen's hernia was first described by Petersen in 1900.^[10] Its boundaries are the inferior edge of the transverse mesocolon, the retroperitoneum, and the Roux limb mesentery.^[11] Although minimally invasive surgery has distinct advantages in the treatment of morbid obesity, there has been increase in the rate of internal hernias.^[3],[12] The incidence of internal hernias after laparoscopic gastric bypass is reported to be 1%–4% and is <1% in open bypass.^[1],[8] However, the true incidence may be underreported due to nonspecific diagnosis and varied timeline of presentation.^[1]

The risk factors for a Petersen's hernia are uncertain and conflicting. Many have reported that the antecolic placement the Roux limb has a higher incidence than retro colic, but the converse also has been seen.^[8] Accordingly, Petersen's hernia is the most common of the internal hernias occurring after an antecolic RYGB.^[13] The other factors implicated in this are massive loss of weight with the associated reduction in the intraabdominal fat that can potentially increase the size of the mesenteric defect.^[4] Hence, several authors have suggested the closure of all the mesenteric defects with permanent running sutures. However, there is no evidence to prove that this technique has reduced the risk of Petersen's hernia.^[1],[6],[12] With ensuing weight loss, these sutures become loose, creating potential spaces.

The presenting complaints in patients with Petersen's hernia are very nonspecific, which poses a major challenge in the diagnosis. In addition, the clinical signs, laboratory, and radiological investigations are also less yielding.^[8] Classically, a CT scan of the abdomen may reveal herniation of the small bowel loop above the level of transverse colon with or without upper abdominal distention.^[9] The other supporting characteristics being a rotation of mesenteric vessels called “whirl” sign, mesenteric fat haziness, displacement of the ligament of Treitz anteriorly, and downward course of the mid-distal ileum in the left hypochondrium.^[14],[15] However, 20%–30% of these patients can have normal CT imaging. Therefore, a diagnostic laparoscopy is prudent to establish the diagnosis to prevent the catastrophe of bowel ischemia and gangrene.^[1],[8]

The treatment for this can be offered laparoscopically where the goal is not only the reduction of the hernia but also a thorough closure of all the mesenteric defects.^[4] In patients who have strangulation and gangrene, resection becomes necessary.^[7] There are no described evidence-based techniques to prevent the occurrence of a Petersen's hernia. Magdy et al. described a novel technique of using a prosthetic bioabsorbable mesh in Petersen's space, reinforced with fibrin glue to prevent the occurrence of hernia.^[16] However, further randomized control trials are required to determine the best methods to prevent this rare, yet potentially life-threatening complication after laparoscopic RYGB.

Conclusion

The incidence of Petersen's space hernia is on the rise due to an exponential increase in the rates of laparoscopic RYGB. The clinical presentation can be at any timeline after the index operation and can be very nonspecific. The laboratory and radiological investigations are also seldom helpful, making the diagnosis very challenging. The threshold to perform a diagnostic laparoscopy should be very low in such patients to avoid the complication of bowel ischemia and gangrene which can be catastrophic. There is no described foolproof method to prevent Petersen's space hernia. The treatment comprises reduction of a herniated segment of the bowel followed by the closure of all the mesenteric defects, which can be done laparoscopically.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Higa KD, Ho T, Boone KB. Internal hernias after laparoscopic Roux-en-Y gastric bypass: Incidence, treatment and prevention. Obes Surg 2003;13:350-4.
2.	Johnson JM, Wood M, Lawson J, Hale HW Jr. Retroanastomotic hernia. Arch Surg 1974;108:363-5.
3.	Morgan H, Chastanet R, Lucha PA Jr. Internal hernia after laparoscopic gastric bypass surgery: A case report and literature review. Postgrad Med 2008;120:E01-5.
4.	Paroz A, Calmes JM, Giusti V, Suter M. Internal hernia after laparoscopic Roux-en-Y gastric bypass for morbid obesity: A continuous challenge in bariatric surgery. Obes Surg 2006;16:1482-7.
5.	Cho M, Pinto D, Carrodeguas L, Lascano C, Soto F, Whipple O, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: Review of 1400 consecutive cases. Surg Obes Relat Dis 2006;2:87-91.
6.	Carmody B, DeMaria EJ, Jamal M, Johnson J, Carbonell A, Kellum J, et al. Internal hernia after laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005;1:543-8.
7.	Reiss JE, Garg VK. Bowel gangrene from strangulated Petersen's space hernia after gastric bypass. J Emerg Med 2014;46:e31-4.
8.	Parakh S, Soto E, Merola S. Diagnosis and management of internal hernias after laparoscopic gastric bypass. Obes Surg 2007;17:1498-502.
9.	Faria G, Preto J, Oliveira M, Pimenta T, Baptista M, Costa-Maia J. Petersen's space hernia: A rare but expanding diagnosis. Int J Surg Case Rep 2011;2:141-3.
10.	Petersen W. Ueber darmveschlingung nach der gastro-enterostomie. Arch Klin Chir 1900;62:94-114.
11.	Rogers AM, Ionescu AM, Pauli EM, Meier AH, Shope TR, Haluck RS. When is a Petersen's hernia not a Petersen's hernia. J Am Coll Surg 2008;207:121-4.
12.	Higa K, Boone K, Arteaga González I, López-Tomassetti Fernández E. Mesenteric closure in laparoscopic gastric bypass: Surgical technique and literature review. Cir Esp 2007;82:77-88.
13.	Comeau E, Gagner M, Inabnet WB, Herron DM, Quinn TM, Pomp A. Symptomatic internal hernias after laparoscopic bariatric surgery. Surg Endosc 2005;19:34-9.
14.	Lockhart ME, Tessler FN, Canon CL, Smith JK, Larrison MC, Fineberg NS, et al. Internal hernia after gastric bypass: Sensitivity and specificity of seven CT signs with surgical correlation and controls. AJR Am J Roentgenol 2007;188:745-50.
15.	Ximenes MA, Baroni RH, Trindade RM, Racy MC, Tachibana A, Moron RA, et al. Petersen's hernia as a complication of bariatric surgery: CT findings. Abdom Imaging 2011;36:126-9.
16.	Magdy M, Suh H, Kuzinkovas V. Novel technique using a bioabsorbable prosthesis with fibrin glue fixation to prevent a Petersen's space hernia. J Surg Case Rep 2017;2017:rjx246.