AbstractBackgroundPetersen's space

Abstract
Background

Petersen's space hernia is caused by the herniation of intestinal loops through the defect between the small bowel limbs, the transverse mesocolon and the retroperitoneum, after any type of gastrojejunostomy. The laparoscopic approach facilitates the occurrence of this type of hernia, due to the lack of post-operative adhesions which prevent bowel motility and hence, herniation.

Case report

We report the case of a 46 year-old male submitted to an open antrectomy and vagotomy with a Roux-en-Y reconstruction six-years before, for the treatment of bleeding gastric ulcer.He presented with epigastric abdominal pain radiating to the back and alimentary vomiting with a 3 days evolution, with an episode of hematemesis 2 h before admission. His abdomen was bloated and tender at the epigastric region. The laboratory exams revealed mild leucocytosis and CRP elevation with normal pancreatic tests. The abdominal CT scan revealed an intestinal occlusion. An exploratory laparotomy was performed, disclosing an incarcerated Petersen space hernia of the common limb, with obstruction and dilatation of the biliary limb.

Conclusion

The knowledge of this anatomic post-operative defect and a low threshold for diagnosis are crucial to its management, since its nonspecific clinical and laboratory findings. Early operative intervention is warranted in order to avoid the severe complications of bowel necrosis.

Keywords: Gastrectomy, Roux-en-Y, Hernia, Intestinal obstruction
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1. Background
Petersen's space Hernia was first described in 1900 by German surgeon, Dr. Walther Petersen.1 It is an internal hernia, arising after any type of gastrojejunostomy (most frequently after Roux-en-Y anastomosis) and it's boundaries are nowadays described as the transverse mesocolon, the retroperitoneum and the Roux limb mesentery2 (Fig. 1).

Fig. 1
Fig. 1
Representation of Petersen space, between the Roux Limb, the Transverse mesocolon and the retroperitoneum.
This type of internal hernia was once very rare and up to 1974, only 178 cases were reported,3 although it's true incidence might be underestimated. It became more frequent in the 1960s and 1970s with the increasing number of antrectomies for peptic ulcer disease. It became again a rare diagnosis with the decline in surgical treatment of peptic ulcer.4 However, in the last few years, it is becoming increasingly frequent with the exponential growth in Laparoscopic Gastric Bypass for the treatment of obesity.5–12 It is even supported by several authors that the use of a laparoscopic approach is a risk factor for this disease, as it prevents the occurrence of post-operative adhesions, which could limit the mobility of the intestinal loops.12

We report a case of Petersen space hernia and perform a brief review of the available literature, underlining its “risk factors”, prevention and treatment.

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2. Case report
We present a case of a 46 year-old male, submitted to an open antrectomy and vagotomy with Roux-en-Y reconstruction six-years before, for the treatment of a bleeding gastric ulcer.

He was observed in our emergency department, complaining of epigastric abdominal pain radiating to the back and alimentary vomiting with a 3-day evolution. Approximately 2 h before he had had an episode of hematemesis. The patient was diaphoretic but with normal vital signs. His abdomen was bloated and tender at the epigastric region and no other abnormalities were found. The laboratory exams revealed mild leucocytosis and CRP elevation with normal pancreatic enzymes.

He was submitted to an upper digestive endoscopy, which revealed a normal Roux-en-Y gastrojejunal anastomosis in an empty stomach. Progressing through the Roux limb, 30 cm distal to the anastomosis, there was the jejuno-jejunal anastomosis with ischemic and haemorragic mucosa (Fig. 2).