Incarceration of the Afferent Loop into the Sutured Closed Mesenteric Defect after Gastrectomy Followed by Billroth-II Reconstruction for Gastric Cancer: Two Case Reports

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INTRODUCTION: Internal hernia is a critical complication after laparoscopic gastrectomy with Roux-en-Y, Billroth-II or double tract reconstruction. It is recommended that mesenteric defects should be closed to prevent internal hernias. We reported two patients who developed internal hernias, in which the afferent loop of Billroth-II reconstruction became incarcerated into the closed mesenteric defects.

CASE PRESENTATION: A man in his late 40s had undergone laparoscopic distal gastrectomy 3 months prior for gastric cancer followed by Billroth-II reconstruction, in which mesenteric defect was sutured closed. The patient visited our hospital complaining of sudden severe upper abdominal pain and was diagnosed with afferent loop obstruction due to an incarcerated internal hernia complicated by acute pancreatitis. Emergency surgery, in which intestinal incarceration was relieved and intestinal ischemia was not found, was performed on the same day as admission. However, postoperative duodenal microperforation occurred, making treatment difficult. A woman in her late 70s had undergone laparoscopic distal gastrectomy 7 days prior for gastric cancer followed by Billroth-II reconstruction, in which mesenteric defect was sutured closed. The patient complained of nausea without abdominal pain and was diagnosed with afferent loop obstruction due to an incarcerated internal hernia. Emergency surgery, in which intestinal incarceration was relieved and intestinal ischemia was not found, was performed on the same day. The patient was discharged uneventfully. In both cases, a hernia orifice formed in the Treiz ligament area, and the afferent loop was incarcerated into the closed mesenteric defect.

CONCLUSIONS: Incarcerated internal hernias should be treated as soon as possible. Although closure of the mesenteric defects after Billroth-II reconstruction is necessary to prevent internal hernias, mesenteric defects should be closed on the left side as far away from the Treiz ligament as possible.