Internal hernia after biliary-enteric drainage surgery

　　The formation of internal hernia after biliary-enteric drainage surgery is mainly caused by the formation of abnormal gaps, the formation of transverse colon mesentery incision, and intestinal dysfunction, increased intraperitoneal pressure, as follows:

　　1. Formation of abnormal gap

　　The main anatomical basis for the formation of internal hernia after biliary-enteric drainage surgery is the change in postoperative anatomy, forming an abnormal gap. During the biliary-enteric drainage surgery, an opening must be made on the transverse colon mesentery, the distal free jejunal loop is passed through this opening and raised to anastomose with the bile duct, forming two abnormal gaps above and below the transverse colon (mesentery). The upper gap, due to the obstruction of the transverse colon and its mesentery, omentum, is rarely caused by the intestinal tract窜入, and even if the intestinal tract窜入, it rarely occurs with intussusception. The lower gap is smaller, and once the small intestine herniates, it is easy to cause intussusception.

　　2. Formation of transverse colon mesentery incision

　　After the jejunal loop passes through the opening of the transverse colon mesentery during surgery, if the repair and fixation is forgotten, or the suture distance is too wide, or the suture is not firmly fixed to the intestinal wall passing through the opening of the transverse colon mesentery, leading to suture line detachment, etc., it can cause the formation of an abnormal incision, which becomes the pathological basis for the formation of internal hernia after biliary-enteric drainage surgery. The jejunal loop can herniate through this gap.

　　3. Intestinal dysfunction and increased intraperitoneal pressure

　　The recovery of postoperative diet, changes in quality and quantity, can cause hyperperistalsis or intestinal dysfunction. If there are factors such as increased intraperitoneal pressure (such as severe abdominal distension) or changes in body position, it is easy to promote the intestinal tract to herniate into the abdominal cavity through the transverse colon mesentery or lower gap.

　　The occurrence of intestinal strangulation and necrosis is the main complication of internal hernia after biliary-enteric internal drainage, at this time, the abdominal symptoms worsen, and systemic toxic symptoms may occur, and severe cases may appear toxic shock.

　　First, duodenal stump rupture

　　Internal hernia occurs in the early postoperative period, as the duodenal stump has not yet healed firmly, and the obstruction caused by the internal hernia of the input loop can lead to the accumulation of bile juice and pancreatic juice in the duodenal lumen, resulting in retentional dilatation, an increase in intraluminal pressure, and eventually rupture.

　　Second, acute pancreatitis

　　A small number of patients may develop acute pancreatitis due to internal hernia, and the reasons are:

　　1. Internal hernia of the input loop causes obstruction, followed by the accumulation of bile juice and pancreatic juice in the duodenal lumen, an increase in intraluminal pressure, leading to the reflux of duodenal fluid into the pancreatic duct, triggering acute pancreatitis.

　　2. Internal hernia of the output loop can also compress the jejunal input loop and cause obstruction, thereby triggering acute pancreatitis, and the blood and urine amylase levels of the patient are significantly elevated.

　　Early biliary-enteric internal drainage patients with internal hernia may have varying degrees of abdominal distension, visible intestinal loops or peristaltic waves; the abdomen is soft, and the swollen intestinal loops can be palpated with mild tenderness; when there is a lot of gas and fluid in the intestinal loops, the sound of gurgling can be heard, and when the intestine is strangulated, the body temperature rises, the heart rate increases, and there may be localized tenderness and peritoneal irritation signs in the abdomen. Sometimes, the strangulated intestinal loop can be palpated, and during colic pain, the sound of water passing through and high-pitched metallic sounds can be heard. At the same time, there are the following symptoms:

　　1. Abdominal pain:It manifests as paroxysmal colic pain, which can last for several seconds or minutes, accompanied by hyperactive bowel sounds, high-pitched bowel sounds, and sometimes the sound of water passing through. If the interval between pain episodes becomes shorter and becomes severe and persistent abdominal pain, it should be considered that intestinal strangulation may occur.

　　2. Vomiting:Early symptoms are reflexive vomiting, with vomit containing food or gastric juice, which can be induced by eating or drinking; in the late stage, the vomit contains intestinal contents.

　　3. Abdominal distension:When strangulation occurs, the abdomen is asymmetrically distended, and enlarged intestinal loops can be felt.

　　4. Stopping of flatus and defecation:After the occurrence of complete intestinal obstruction, patients often no longer pass gas or defecate.

　　After biliary-enteric anastomosis, it should be routinely sutured to seal the submesenteric space of the transverse colon, which has a positive significance in preventing the herniation of the small intestine into the hiatus after surgery and preventing the occurrence of internal hernia after biliary-enteric internal drainage.

　　1. Choose the appropriate anastomosis method

　　Since the duodenojejunal flexure of most individuals is located on the left side of the spine, the anastomosis of the jejunal input loop in front of the colon can cause anatomical disorders such as the anterior and posterior crossing of the jejunal loop with its mesentery, and it requires a longer input loop, thus it is prone to cause postoperative internal hernia. It is recommended to adopt the anastomosis of the jejunal input loop behind the colon to the small curvature or the anastomosis of the colon in front of the large curvature to shorten the length of the jejunal input loop and avoid the crossing change of the bowel and mesentery.

　　2. Postoperative diet and the recovery of physical labor should be appropriate

　　The quality and quantity of food and the gastrointestinal dysfunction are closely related, especially in the case of abdominal surgery with certain adhesions in the abdominal cavity, strenuous physical activity after a full meal or overeating is more likely to cause gastrointestinal motility dysfunction and trigger internal hernia, which should be avoided as much as possible. After stomach surgery, eat small and frequent meals, prefer light and easy-to-digest foods, and avoid strenuous physical activity after meals.

　　3. Reliable mesentery opening repair

　　The opening of the transverse colon mesentery is at the root, and the repair and fixation should be reliable, not too high, to avoid the occurrence of a transverse colon mesentery fissure.

　　Blood tests and X-ray examinations should be performed for internal hernia after biliary-enteric diversion surgery, as follows:

　　1. Hemoglobin and hematocrit:Increased due to dehydration and blood concentration.

　　2. White blood cell count and classification count:Consider bowel strangulation if they are significantly elevated.

　　3. Serum electrolytes (K, Na, Cl-):Reflects the condition of electrolyte imbalance in the body.

　　4. Blood gas analysis:Reflects the condition of acid-base imbalance in the body.

　　5. Examination of vomit and feces:Consider the presence of bowel ischemia if there are a large number of red blood cells or positive occult blood.

　　6. X-ray examination:After 4 to 6 days of intestinal obstruction, X-ray examination shows gas in the intestinal lumen, and standing or lateral position films show multiple liquid levels and gas-filled intestinal loops.

　　Patients with internal hernia after biliary-enteric diversion surgery should have a light diet. In the first few days after surgery, diet should be adjusted according to individual conditions, with a focus on liquid and semi-liquid foods. Eating more high-protein foods is beneficial for wound healing. Supplementing a variety of vitamins, eating more fresh vegetables and fruits. Various lean meats, milk, eggs, and other protein-rich foods can be eaten more. Patients should avoid eating greasy foods and should not choose foods such as preserved bean curd, scallions, chili peppers, and chives, as these foods are不利于 wound healing because they are prone to cause infection.

　　The clinical manifestations of internal hernia after biliary-enteric diversion surgery are the symptoms and signs of acute mechanical small bowel obstruction, and early surgical treatment is required. Once diagnosed or suspected, an early laparotomy should be performed to confirm the diagnosis, reduce the herniated and incarcerated bowel, and seal the fissure.