Laparoscopic Repair of a Paraesophageal Hernia After Gastric Bypass for Morbid Obesity with Repair of an Incidental Internal Hernia and Gastro-gastric Fistula.

Background: This video illustrates the use of laparoscopic techniques to repair a paraesophageal hernia after roux-en-y gastric bypass as well as repair of both an internal hernia and a gastro-gastric fistula that were discovered at the time of surgery.

Case Report: We present a fifty-year-old female with a history of prior roux-en-y gastric bypass (RYGBP) for morbid obesity who presented with significant reflux and regurgitation. Her symptoms included significant heartburn and a persistent cough that was worse with food and triggered nocturnally. The patient was taking proton pump inhibitors for these symptoms. Her extensive work up that included an upper GI series and endoscopy was significant for erosive esophagitis in the lower one third of the esophagus and erosions noted at the gastrojejunostomy anastomosis of the roux-en-y bypass. The upper GI series revealed a small hiatal hernia and a secondary finding of mildly dilated loops of small bowel. The patient underwent a laparoscopic repair of a sliding hiatal hernia. During the procedure an internal hernia was diagnosed as an incidental finding. The hernia defect was reduced and closed. A gastro-gastric fistula was also discovered that was divided and over sewn. Both of these findings may have contributed to the patient’s symptoms of reflux. The patient had an uneventful post-operative course.

Conclusion: Paraesophageal hernias after RYGBP can be the source of Gastroesophageal reflux disease (GERD) like symptoms. The laparoscopic repair seems to be a secure and reasonable approach to this problem. Thorough evaluation of the anatomy is recommended in order to rule out other incidental findings such as internal hernias or fistulas.

Session: Video Channel

Program Number: V048

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