Jessica Ardila-Gatas, MD, Linden Karas, MD, Ali Aminian, MD. Cleveland Clinic
Introduction: In patients with morbidly obesity and gastroesophageal reflux disease (GERD), a Roux-en-Y gastric bypass (LRYGB) is the procedure of choice, since it solves both problems. Repair of paraesophageal hernias remains a challenge for the general surgeons. Complete reduction of the hernia sac, adequate intra-abdominal esophageal length and a tension free intra-abdominal repair are crucial to prevent anatomic and symptomatic recurrence. In the obese patient with higher risk of recurrence additional reinforcement of the crura may need to be done to prevent it from happening. Here we show a case of posterior gastropexy for hiatal reinforcement.
Case Presentation: This is a 53 year old woman who presented with dysphagia, nausea and emesis. She is morbidly obese (BMI 35) with GERD and other weight related co-morbidities. She underwent upper endoscopy and computed tomography that showed a large hiatal hernia. She was taken to the operating room for a LRYGB and paraesophageal hernia repair. Upon entering the abdominal cavity a large hiatal hernia was seen. The initial step was creation of the jejunojejunostomy. The jejunum was divided 50 cm from the ligament of Treitz. The Roux limb was then measured 150 cm distally, and was approximated to the biliopancreatic limb, and a stapled end-to-side enteroenterostomy was constructed. The mesenteric defect was closed. The Roux limb was then advanced antecolic. A type III paraesophageal hernia was identified. The gastrohepatic ligament was divided, the right crus was opened and dissection carried circumferentially towards the left crus. The esophagus was isolated and circumferential dissection in the mediastinum was done until the hernia sac was completely reduced. The crura was closed primarily posteriorly. A relatively long gastric pouch was made. A posterior reinforcement of the crura was constructed by suturing the fundus (gastric remnant) to the right crus. A hand-sewn 2 layer end-to-side gastrojejunostomy anastomosis was performed. Patient recovered well and was discharged on postoperative day 2. At her one month follow-up she remained well, no signs of recurrence and appropriate weight loss.
Discussion: Paraesophageal hernia repair with posterior crura reinforcement is a feasible option to potentially reduce the recurrence risk of a hiatal hernia in the obese patient after LRYGB.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85541
Program Number: V121
Presentation Session: Friday Exhibit Hall Theater (Non CME)
Presentation Type: EHVideo
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