Fig. 14.32  Application of fibrin glue on bleeding staple lines

Late Postoperative Complications

Internal Hernia. Persistent colicky abdominal pain with vomiting in a patient after Roux-en-Y gastric bypass can be indicative of an internal hernia. Even if the mesenteric defect was closed in the original operation, it may enlarge as the patients lose weight and allow a loop of bowel to herniate (Fig. 14.33). The diagnostic tool of choice is a CT scan with IV and oral contrast, which will show a swirl of the mesenteric vessels around the internal hernia – the Cinnamon Roll sign. In this case, or if there is a high clinical suspicion for internal hernia, the patient should be taken back to the operating room. After insufflation and placement of a set of triangulated trocars, the ileal-cecal junction is found and bowel is run towards the ligament of Treitz. When the hernia is found, the small bowel is reduced and the mesenteric defect is closed with a nonabsorbable suture (Fig. 14.34). Fibrin sealant is applied over the defect (Fig. 14.35).

A grave complication is torsion of the small bowel, and more specifically torsion of the Roux limb. This is especially true with a long loop measuring more than 100 cm, as is the case in patients with a BMI greater than 50. When positioning the Roux-en-Y limb, it is possible to have a loose 360° torsion of the Roux limb, and the patient will present with multiple admissions to the ER with symptoms of vomiting and abdominal pain that resolve spontaneously. A contrast CT can be diagnostic, but more often, a diagnostic laparoscopy will find this rare complication. The only solution is to redo the gastrojejunostomy (Fig. 14.36).