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Diagnosis of Transmesocolic Internal Hernia as a Complication of Retrocolic Gastric Bypass: CT Imaging Criteria

¹ Department of Radiology, Baylor University Medical Center, 3500 Gaston Ave., Dallas, TX 75231.
² Department of Surgery, Baylor University Medical Center, Dallas, TX.

View larger version (64K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Drawing shows mesocolic defect (arrow) through which protrusion of multiple loops of small bowel results in internal hernia.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —29-year-old woman after gastric bypass. Axial CT image shows normal appearance of proximal gastrojejunostomy with single efferent Roux-en-Y limb (arrow) adjacent to gastric pouch.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —37-year-old woman after gastric bypass. Axial CT images 10 mm apart show multiple redundant loops of small bowel (solid arrow) adjacent to pouch (dashed arrow, A) in left upper quadrant.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —37-year-old woman after gastric bypass. Axial CT images 10 mm apart show multiple redundant loops of small bowel (solid arrow) adjacent to pouch (dashed arrow, A) in left upper quadrant.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —31-year-old woman after gastric bypass. Axial CT image shows multiple loops of small bowel (solid arrow) adjacent to proximal anastomosis (dashed arrow) above level of spleen.

View larger version (146K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5 —46-year-old woman after gastric bypass. Axial CT image shows normal appearance of distal jejunojejunostomy (arrow), which normally is located at level of middle portion of left kidney.

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6 —38-year-old woman after gastric bypass. Axial CT image shows distal jejunojejunostomy anastomosis (solid arrow) at level of tightly clustered vessels (dashed arrow) indicating mesocolic defect and suture lines from proximal gastrojejunostomy. Findings are consistent with high position of anastomosis.

View larger version (134K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —27-year-old woman after gastric bypass. Axial CT image at level of middle of spleen shows displacement of anastomosis toward superior aspect (arrows).

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8 —26-year-old woman after gastric bypass. Axial CT image shows tightly clustered ascending vessels (arrow) indicating level of mesocolic defect.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —34-year-old woman after gastric bypass. Axial CT image shows dilated efferent jejunal limb (arrow).

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10 —27-year-old woman after gastric bypass. Axial CT image shows dilated efferent jejunal limbs (solid arrow) and pinching of jejunal efferent limb (dashed arrows) as it passes through mesocolic defect.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11 —38-year-old woman after gastric bypass. Axial CT image shows pinching of jejunal efferent limb (arrow) where it passes through mesocolic defect.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —Overview of retrocolic Roux-en-Y gastric bypass procedure. (Reprinted with permission from www.laparoscopy.com; courtesy of Schauer P, Cleveland Clinic, Cleveland, OH) Drawing shows construction of small gastric pouch (arrow). Inset shows use of surgical stapler to make pouch.

View larger version (109K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —Overview of retrocolic Roux-en-Y gastric bypass procedure. (Reprinted with permission from www.laparoscopy.com; courtesy of Schauer P, Cleveland Clinic, Cleveland, OH) Drawing shows construction of retrogastric–retrocolic tunnel (circle) in mesocolon anterolateral in relation to ligament of Treitz. Roux limb will be passed through tunnel.

View larger version (174K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12C —Overview of retrocolic Roux-en-Y gastric bypass procedure. (Reprinted with permission from www.laparoscopy.com; courtesy of Schauer P, Cleveland Clinic, Cleveland, OH) Drawing shows distal end of Roux limb attached to proximal segment of jejunum (arrowhead) approximately 15–30 cm from ligament of Treitz. Proximal end (dashed arrow) of Roux limb is pulled through mesocolic tunnel (circle).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12D —Overview of retrocolic Roux-en-Y gastric bypass procedure. (Reprinted with permission from www.laparoscopy.com; courtesy of Schauer P, Cleveland Clinic, Cleveland, OH) Drawing shows anastomosis between gastric pouch (solid arrows) and proximal Roux limb (dashed arrows). Inset shows stapled anastomosis reinforced with stitches.

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