A Case of Acute Complication of Internal Hernia after Total Gastrectomy

Abstract

A-61-year-old male underwent total gastrectomy and Roux-en-Y reconstruction for gastric carcinoma. He suffered from hiccup and bloody vomiting about 12 hours after surgery. Decompression using a nasogastric tube was able to gradually reduce the symptoms, however the laboratory data showed a C-reactive protein level of 26mg/dL on the 2nd postoperative day. As a result, we used plain CT to determine whether there was an anastomotic leakage or intraperitoneal abscess. Since we could not find any clear obstruction or abscess for the dilatation of the afferent and efferent loops, we performed decompression again in the same manner. Abdominal CT scan with the administration of gastrointestinal contrast via a nasogastric tube on the 3rd postoperative day demonstrated marked dilatation of the jejunum from the esophagojejunal anastomosis to the jejuno-jejunostomy, and increased ascites. We performed an emergency laparotomy under the diagnosis of strangulated ileus due to an internal hernia. We confirmed necrosis of the majority of the hanging jejunum, with the hanging jejunum on the anal side from the transverse mesocolon strangulated via counterclockwise insertion into the gap between the hanging mesojejunum and the transverse mesocolon. The patient underwent a second operation for removal of the necrotized intestine and Roux-en-Y reconstruction, and he was discharged from hospital with a good postoperative course on the 18th day after reoperation. We should recognize the complication of an internal hernia from several hours after total gastrectomy and Roux-en-Y reconstruction, as in this case.