An Unusual Complication of Internal Hernia Post-laparoscopic Sleeve Gastrectomy: A Video Case Report

Internal hernia is a well-recognized complication after laparoscopic Roux-En-Y gastric bypass. Recently, it has been recognized after laparoscopic one-anastomosis gastric bypass. Alteration of bowel anatomy was put as the cause of internal hernia after these procedures.  Laparoscopic sleeve gastrectomy (SG) is one of the most commonly performed bariatric procedures worldwide; it was hypothesized that internal hernia could not occur after sleeve gastrectomy. We report in a video a case of internal hernia that occurred post laparoscopic sleeve gastrectomy and its concomitant management. Data on the case of post-SG internal hernia were collected retrospectively and reported in a video with its intra-operative findings and concomitant management. The patient is a 35-year-old male. He underwent laparoscopic sleeve gastrectomy, which was complicated by a leak. It was managed conservatively with optimal clinical response. He presented seven years after his surgery to the emergency department with a history of multiple episodes of severe left upper abdominal pain. a CT scan was performed, showing suspicion of an internal hernia. The patient was taken for emergency laparoscopic exploration.  Intra-operatively, there was a band of adhesion from a previous leak site connecting a loop of proximal jejunum to the anterior abdominal wall, forming a 5 cm defect. Through it, a loop of bowel was found herniating with partial twisting of its mesentery and engorgement of its vessels. In addition, there were multiple adhesions between bowel loops. The herniated bowel loop was reduced with no evidence of ischemia. The adhesive band was resected using a laparoscopic linear stapler. The bowel was fully inspected from the ileocecal valve up to the duodenojejunal (DJ) flexure, and a full adhesiolysis was performed. The patient recovered well. He was discharged on day one postoperatively. He was followed up with a complete resolution of his symptoms and no complications. We conclude that an internal hernia could occur as a long-term complication of sleeve gastrectomy leaks. A high index of suspicion should be applied when dealing with vague abdominal pain post-bariatric surgery. The laparoscopic approach was safe and feasible.