Laparoscopic Repair of Hiatal Hernia With Dor Fundoplication After Sleeve Gastrectomy in a Patient With Intractable GERD and Retained Gastric Body

Andre Teixeira, MD MBA MPH, Carolina Ampudia, MD, Samuel Szomstein, MD FACS FASMBS, Raul Rosenthal, MD FACS FASMBS. Cleveland Clinic Florida

 Introduction: Sleeve gastrectomy is one of the newest procedures and one of the fastest growing surgeries in the bariatric armamentarium. Technical details of the sleeve are important and failure to adhere to strict technical guidelines may result in complications.

Materials and Methods: A 26-year-old female status post vertical sleeve gastrectomy performed in a different institution 2 years ago presented to our office with severe gastroesophageal reflux disease (GERD) refractory to medical therapy. UGI revealed severe reflux and a hiatal hernia.

The patient underwent a laparoscopic reoperation. Using sharp dissection, the sleeve was dissected off the liver. The liver is cranially retracted. Adhesions to the anterior wall of the stomach were sharply taken down. Right and left crus of the diaphragm were dissected and a somewhat large fundic remnant was identified, isolated and reduced into the abdominal cavity. The diaphragmatic crus was closed posteriorly with a running double layer of quills 2-0 Prolene sutures. Anteriorly another 2-0 silk suture was used to reinforce the hiatus. An Ewald tube was passed and the retained fundus was then sutured with 2 interrupted 2-0 silk sutures to the lesser side of the esophagus in an attempt to create a Dor type fundoplication.

Result: The recovery of the patient was uneventful, with a normal UGI on POD1 without leak or obstruction. The patient presented to the office 2 weeks postoperative and she was completely off the PPI and no symptoms of reflux were present.

Conclusion: Sleeve gastrectomy is accepted as an effective surgical option for treatment for morbid obesity. Strict technical guidelines and an excellent preoperative workup need to be followed in order to prevent complications from the operation. Sleeve gastrectomy creates a high-pressure system that can make GERD unbearable for patients with hiatal hernia and incompetent lower esophageal sphincters. The use of an anterior fundoplication type Dor can be a feasible alternative for patients with GERD.

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