Laparoscopic Hiatal Hernia Repair during in-Sleeve Gastrectomy

Abstract

Obesity is one of the most important health problems in developed and developing countries. Morbid obesity is defined as having a body mass index (BMI) of more than 40 kg/m2. Obesity does not only predispose to gastroesophageal reflux, but is also an important independent risk factor for the development of hiatal hernia (HH). There are articles advocating about half of obese patients have a hiatal hernia. Hiatal hernia not only exacerbates reflux symptoms, but may also lead to incomplete removal of the gastric fundus during laparoscopic sleeve gastrectomy (LSG). When hiatal hernias are seen preoperatively or intraoperatively for bariatric surgery, surgical correction should ideally be made with mesh reinforcement to prevent further clinical progression.

1. Introduction

Obesity has an important place among the most important health problems of developed and developing countries [1, 2, 3]. If the body mass index (BMI), calculated by evaluating the height and weight together, is greater than 40 kg/m², it is called morbid obesity. Along with obesity, the risk of systemic diseases such as diabetes mellitus (DM), obstructive sleep apnea and cardiovascular diseases increases, resulting in an increase in mortality rates. However, one of the independent risk factors for the development of gastroesophageal reflux disease (GERD) is obesity. In addition to predisposing to gastroesophageal reflux, one of the important independent risk factors for the development of hiatal hernia (HH) is obesity [4, 5, 6, 7, 8].

On the other side, the hiatal hernia (HH) is closely related to the presence of GERD.

2. Discussion

Gastroesophageal reflux disease (GERD) and HH have a relatively high incidence in the morbidly obese population, the underlying pathophysiology is transient lower esophageal sphincter relaxation in combination with increased intra-abdominal pressure [9].

It has been proven that obesity is an important independent risk factor for the development of GERD and/or HH; while approximately 50–70% of patients undergoing bariatric surgery for morbid obesity have symptomatic reflux, 15% of them have symptomatic HH. GERD and HH are closely related with high BMI [10]. There are studies indicating the prevalence of GERD (defined as an increase in acid exposure and/or fissures in the esophageal mucosa) as 41% before laparoscopic sleeve gastrectomy (LSG) and 71% after LSG [11, 12].

There are articles advocating about half of obese patients have a hiatal hernia [5, 13]. Hiatal hernia not only exacerbates reflux symptoms, but may also lead to incomplete removal of the gastric fundus during LSG [3]. With the increasing use of LSG, more patients have been observed with relatively common side effects such as GERD and other somewhat rare anatomical complications such as strictures, ulcerations, and HH [14]. Small esophageal sliding herniation of LSG is thought to be associated with GERD after LSG, therefore surgical repair of HH is advocated by many [15]. Gastric narrowing, progressive enlargement of the esophageal hiatal opening, division of natural connections such as the phrenoesophageal membrane, and removal of the gastric fundus near the angle of His are possible factors associated with postoperative weight loss and reduction in visceral fat, and intrathoracic migration of the stomach [16]. Some authors have suggested that previous hiatal hernia repair (HHR) may accelerate postoperative LSG migration due to hiatal dissection, which may lead to phreno-esophageal membrane disruption, gastric sleeve instability, and associated loss of antireflux mechanisms [17].

In a study by Daes et al., it was found that hiatal hernia was detected intraoperatively in 25% of patients undergoing LSG, and reflux symptoms were significantly reduced after hiatal hernia repair (HHR) [18]. Baumann et al. [16], using multisection computed tomography, monitored 27 patients with gastric sleeve and they found that the migration of the staple line to the thorax is associated with the presence of gastroesophageal reflux. Interestingly, they demonstrated a 37% migration rate of the gastric sleeve into the posterior mediastinum 1–10 months after surgery. While 40% of these patients complained of reflux symptoms, 60% were asymptomatic. Most studies like this show an improvement in GERD when the hernia is repaired [19].

In the light of this information, if the presence of a hiatal hernia is known before bariatric surgery or if a hiatal hernia is detected during surgery, it is recommended to repair it [20, 21, 22]. In bariatric surgery, if it is detected in the preoperative evaluation or intraoperatively, concomitant repair should be performed [23, 24]. The repair of hiatal hernia during a gastric sleeve due to morbid obesity decreases the prevalence of GERD. It was revealed that dyspeptic symptoms and reflux symptoms regressed after HHR and that proton pump inhibitor usage declined. Unsuccessful hiatal hernia repair (HHR) can lead to an exacerbation of reflux symptoms after surgery. There are authors who advocate anterior and posterior placement of sutures in HHR to prevent anterior hiatal dilation during weight loss [25]. There are also articles in the literature reporting that HHR was performed safely with a mesh after LSG [26, 27].

3. Management and treatment

Fundoplication after bariatric surgery is not technically possible due to the lack of excess stomach tissue due to previous sleeve gastrectomy. Mesh reinforcement has been proven to have a lower incidence of recurrence than primary repair. Although there is no difference in complication rates between synthetic and biological mesh, it has been proven that synthetic mesh has a lower recurrence rate compared to biological mesh [28].

A randomized controlled trial conducted by Snyder at al [29] showed no difference between repairing and not performing HH during sleeve gastrectomy. Santonicola et al. [30] showed the results of repairing HH during gastric sleeve in 78 patients. The incidence of preoperative reflux was 38.4%, and 30.8% after 15 months of follow-up (p = 0.3). Dakour Aridi et al. studied the safety of repairing HH during gastrectomy [31]. The 28,000 patients who had only sleeve gastrectomy and 4687 patients who had sleeve gastrectomy + HH repair recorded in the database of the National Surgical Quality Improvement Program were compared. Examined groups were not different from each other in terms of complications and mortality. In fact, there were no unexpected or adverse outcomes of performing esophageal dissection and performing hiatus repair. In addition, some anatomical and physiological results of sleeve gastrectomy surgery can explain the regression in preoperative symptoms. With LSG, the total gastric mucosal surface and, accordingly, the amount of acid-producing parietal cells are reduced. In addition, gastric emptying increases and intra-abdominal pressure decreases as total weight decreases. These may explain the improvement in symptoms without HH repair.

Soricelli et al. [32] published 6 patients who underwent HH repair during LSG. In 2 patients with hiatal defects larger than 5 cm, polypropylene mesh was suitable following crus repair, while crus repair was performed with 2 or 3 sutures with non-absorbable suture materials in the other 4 patients. No complications were observed during or after the operation, but HH recurrence was detected in 1 (17%) patient during long-term follow-up. In the literature, there are authors suggesting to use bio-absorbable mesh if HH repair is required during LSG, or to fix the remaining stomach to the colonic mucosa with bio-absorbable mesh, thus preventing both migration in the remaining stomach and possible volvulus [33, 34]. Occlusion of the esophagus due to imprisoned HH in the early postoperative period secondary to crus repair can be seen as a very rare complication. To the best of our knowledge, only one case was reported by Mizrahi et al. [35] in the literature. This potential complication does not change the fact that it is safe to perform HH repair if necessary during LSG. We think that conversion to Laparoscopic Roux and Y gastric bypass (LRYGB), in which the alimentary limb is fixed to the diaphragm, is the most appropriate option due to the presence of a short intra-abdominal esophagus and the tension in the sleeved stomach in patients where LSG and hiatoplasty are applied together and no success is achieved. Our biggest concern in the reoperation was how to prevent the reherniation of the stomach with a tube. While making our decision, we considered that the transition to LRYGB could provide several advantages; (1) it is an anti-reflux procedure in itself, (2) traction produced by the small intestine anatomically placed in the gastric pouch can help hold the stomach in place (3) Unlike LGS, it is a low pressure system. Also, fixing the blind loop of the alimentary limb to the diaphragm provides further fixation.

With regard to strengthening the hiatal repair with a patch, it is performed in symptomatic cases where the hiatal defect is >5 cm (detected intraoperatively) and where it is not possible to bring the cruses closer together without tension. Nocca et al. [12] and our experience it has been proven that this technique significantly reduces the recurrence rate of HH in patients with a hiatal defect >5 cm.

In cases, crural repair was performed by means of two or three interrupted non-absorbable stitches (Figures 1–3), while in the two cases with a HH > 5 cm, a U shaped polypropylene mesh was superimposed to aid crural closure.

Figure 1.

Large hiatus/sleeve stapled line.

Figure 2.

Laparoscopic view of gastric sleeve herniation through esophageal hiatus.

Figure 3.

(a) Laparoscopic view hiatal hernia repair. (b) Final aspect closed esophageal hiatus.

4. Conclusions

When hiatal hernias are seen preoperatively or intraoperatively for bariatric surgery, surgical correction should ideally be made with mesh reinforcement to prevent further clinical progression. Prosthetic reinforcement of the hiatal closure should be performed in selected cases where an increased risk of HH recurrence exists. To evaluate the effectiveness of this procedure and as well as the feasibility and safety of prosthetic hiatal closure, further series with larger numbers of patients and longer follow-up are needed.

Conflict of interest

The authors declare no conflict of interest.