Retroanastomotic Hernias

Retroanastomotic hernias occur usually in patients who have undergone partial gastrectomy and gastrojejunostomy, particularly of the antecolic variety.11,86 The superior border of the hernial ring is formed by the transverse mesocolon, the inferior border by the ligament of

Treitz, and the anterior aspect by the gastrojejunostomy together with the afferent limb of the jejunum11 (Fig. 16-51). The herniated loop is usually the efferentjejunal segment or, less commonly, an excessively long afferent limb that protrudes into the retroanastomotic space.

About half of these hernias manifest themselves within 1 month and another 25% within 1 year after the operation,87 with symptoms of cramping abdominal pain and signs of a high small bowel obstruction. These nonspecific findings may be mistaken for stomal edema, dumping, or pancreatitis, and the correct diagnosis may be delayed until strangulation has developed.10,11,87 This contributes to the reported mortality rate of 32% for surgically treated cases and almost 100% for untreated patients.11

Careful fluoroscopic evaluation discloses that the obstruction is situated not at the gastric stoma but more distally in either of the anastomotic limbs. Gradual opa-cification of the partially obstructed efferent loop shows its abnormal position just lateral and posterior to the gastrojejunostomy (Fig. 16-52). Some degree of dilatation and stasis is usually associated.

Mri Falciform Ligament

Fig. 16—49. Small bowel herniation through the falciform ligament.

(a) Postcontrast CT demonstrates multiple dilated fluid-filled small bowel loops (black asterisks) anterior to the stomach (st). They show inhomogenous enhancement of a thickened bowel wall. These loops are tethered toward the site of volvulus to the left of the level of the falciform ligament; to the right, the thin-walled loops proximal to the obstructing hernia are air-filled and dilated (white asterisks). Collapsed distal small bowel with gas bubble can be identified (small arrow). Fluid (a) is seen around the liver and in the small bowel mesentery.

(b) Diagram of surgical findings, showing jejunal herniation from right to left through a rent in the falciform ligament (FL) between the ligamentum teres (LT) and the anterior abdominal wall. Volvulus with infarction involves the herniated segment on the left side.

(Reproduced from Walker and Baer.83)

Fig. 16—49. Small bowel herniation through the falciform ligament.

(a) Postcontrast CT demonstrates multiple dilated fluid-filled small bowel loops (black asterisks) anterior to the stomach (st). They show inhomogenous enhancement of a thickened bowel wall. These loops are tethered toward the site of volvulus to the left of the level of the falciform ligament; to the right, the thin-walled loops proximal to the obstructing hernia are air-filled and dilated (white asterisks). Collapsed distal small bowel with gas bubble can be identified (small arrow). Fluid (a) is seen around the liver and in the small bowel mesentery.

(b) Diagram of surgical findings, showing jejunal herniation from right to left through a rent in the falciform ligament (FL) between the ligamentum teres (LT) and the anterior abdominal wall. Volvulus with infarction involves the herniated segment on the left side.

(Reproduced from Walker and Baer.83)

Fig. 16—50. Hepatojejunostomy simulating a hernia through the falciform ligament.

In this patient with a cholangiocarcinoma of the common bile duct, surgical anastomosis of a jejunal loop to the left hepatic duct mimics the appearance of herniation through the falciform ligament.

Fig. 16—51. Lateral drawing of the retroanastomotic hernial ring in the antecolic gastrojejunostomy.

Fig. 16—51. Lateral drawing of the retroanastomotic hernial ring in the antecolic gastrojejunostomy.

Billroth Series Gastroduodenal

Fig. 16—52. Retroanastomotic hernia.

Upper GI series post-Billroth II shows the herniated efferent loop encapsulated in the left upper quadrant (arrows). The afferent loop with a duodenal diverticulur also opacified with barium.

(Courtesy of Gary G. Ghahremani, M.D., Evanston Hospital, Evanston, IL.)

Anticolic Loop Gastrojejunostomy
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Essentials of Human Physiology

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