Laparoscopic internal hernia reposition after laparoscopy-assisted distal gastrectomy with Roux-en-Y reconstruction

After undergoing laparoscopy-assisted distal gastrectomy with antecolic Roux-en-Y reconstruction for early gastric cancer, a 49-year-old woman was seen for dull abdominal pain and epigastric discomfort. Her abdomen was not distended and no gross peritoneal signs were seen beyond midabdominal tenderness upon palpation. Plain abdominal radiography showed no bowel obstruction, but abdominal computer tomography showed bowel and mesenteric vessel twisting (whirl sign). When conservative treatment based on a diagnosis of internal hernia was unsuccessful, we conducted laparoscopic surgery the next day, finding that the entire small intestine from the jejunojejunostomy to the end of the ileum had herniated through the Petersen's defect and was misplaced on the left side of the abdomen. With drawing the small intestine from the Petersen's defect and repositioning it laparoscopically obviated intestinal resection since the herniated intestine had no ischemic change. Internal hernia following distal gastrectomy is rare, but the incidence of Petersen's hernia is expected to increase with the increasing incidcence of Roux-en-Y reconstruction. Prompt diagnosis remains the most important factor in reducing internal hernia morbidity. © 2010 The Japanese Society of Gastroenterological Surgery.