You get called to see a consult in the middle of the night. It is a middle-aged woman with a bariatric history, and she says her stomach is smaller but doesn’t know the name of the operation. She developed worsening abdominal pain after dinner and it’s been getting worse. She’s not peritonitic, but she’s clearly in discomfort. Is it cholecystitis, diverticulitis, pancreatitis, marginal ulcer, or an internal hernia? What do you do? Join Drs. Matthew Martin, Adrian Dan, and Paul Wisniowski on a discussion about initial evaluation and management of bariatric patients with internal hernias. 

Show Hosts:
Matthew Martin
Adrian Dan
Paul Wisniowski

Show Notes
1.     Initial Evaluation
a.     Focused history and physical, labs, and imaging
                                      i.     Presenting symptoms may vary and include: nausea, emesis, and abdominal pain ranging from vague to severe.  
                                     ii.     A basic lab panel can aid in developing the diagnosis and guide resuscitation.
                                    iii.     CT of the abdomen and pelvis with IV and oral contrast can assist in identifying intra-abdominal pathology
                                    iv.     Reviewing the previous operative report is beneficial to have a framework of the anatomy, i.e. type of bariatric surgery, and configuration of small bowel limbs (ante- vs retro-gastric and ante- vs retro-colic).
1.     According to a 2019 study, 40-60% of closed defects had reopened at time of re-exploration 
                                     v.     If the patient is peritonitic with abdominal pain, they should be treated similarly to any patient with an acute abdomen with emergent exploration.
b.     CT Imaging 
                                      i.     A mesenteric swirl sign with twisting of the soft tissue and mesenteric vessels with surrounding fat attenuation has been shown to have a sensitivity of 78-100% and specificity of 80-90%. Other findings include: a Bird’s beak, dilation of roux or biliopancreatic limbs, SMV narrowing, and displacement of JJ limb to the RUQ and can be used to support the diagnosis of internal hernia
                                     ii.     An experienced radiologist familiar with bariatric anatomy has been shown to have a positive predictive value to 81% and negative predictive value to 96% at radiologically diagnosing internal hernia. 
                                    iii.     A CT scan can provide insight for a suspected diagnosis but it cannot rule out internal hernia
c.      Nasogastric/Esophageal Tube
                                      i.     Use judiciously based on patient’s presenting symptoms
                                     ii.     Placement should be done by the surgical team 
                                    iii.     This may mitigate the risk of aspiration during intubation.
2.     Operative Management
a.     Entry should be dependent on the comfort of the operating surgeon. 
                                      i.     Veress entry into the abdomen with dilated bowels may lead to increased injuries. 
                                     ii.     Optiview allows for direct visualization of each layer of the abdominal wall. Focusing on twisting the trochar and limiting perpendicular pressure. 
                                    iii.     Hasson entry also allows for direct visualization but may be limiting in bariatric patients with thick abdominal walls
b.     Exploration – a systematic approach
                                      i.     Start with evaluation of the gastric pouch and run the roux limb to the jejunojejunostomy, and examine Petersen’s and mesojejunal defects. 
                                     ii.     Follow the biliopancreatic limb to the ligament of Treitz
                                    iii.     Lastly, identify the terminal ileum at the sail of Treves and run backwards to the jejunojejunostomy
                                    iv.     Thi