Presentation
Severe LUQ pain and peritonism. Retrocolic Roux-en-Y surgery 8 months ago.
Patient Data
Angled and crowded mesenteric vessels in the LUQ spreading into a 'mushroom'-like cluster of edematous small bowel loops. Minor free fluid and large draining lymph nodes.
Dilated fluid-filled Roux limb. Thick-walled distal biliopancreatic limb and jejunostomy in the abnormal cluster. Edematous distal transverse colon compressed and displaced posteriorly.
Case Discussion
Past history of antecolic Roux-en-Y and gastric sleeve.
Localized LUQ collection of 'weeping' edematous bowel and mesentery with large lymph nodes and mesenteric swirl which was interpreted as transmesocolic internal hernia. Two prior admissions since surgery with intermittent abdominal pain is a typical but non-specific presentation. However the surgical findings did not support this. Instead, a focal adhesion was found and divided.
Transmesocolic hernia is a complication specific to retrocolic Roux-en-Y bypass. The signs are:
small bowel loops in the LUQ between the stomach and spleen, superior to the transverse mesocolic defect
superiorly displaced jejunojejunostomy which should lie about the left of the left renal hilum
clustered proximal SMA branches heading towards the LUQ which may be pinched where they traverse the mesocolic defect
dilatation of the Roux limb is variable and is related to severity of symptoms and/or obstruction.
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