Hiatal hernia is a common disease with a high prevalence among population with obesity due to the increase in the intra-abdominal pressure.
We present a case of a 67 years old female with severe reflux symptoms of 2 months of evolution that did not resolve with medication. She had a surgical history of Roux en Y Gastric Bypass and Hiatal hernia repair in the same operative procedure 11 years ago. In the OR after accessing the abdominal cavity the liver was cranially retracted. GE junction was exposed and a type 2 hiatal hernia with herniation of the pouch into the mediastinum was visualized. We dissected between the pouch, Liver, the right and left crus of the diaphragm until we were able to take down and reduce the pouch into the abdominal cavity. We reestablished the length of the intra-abdominal esophagus, then the diaphragmatic crus was suture posteriorly and anteriorly with running and figure of eight with 2.0 Prolene Quill Suture respectively, the pouch was then fixated to the triangular ligament with interrupted 0 silk sutures.
The procedure was completed without complications and the patient tolerated it very well, with minimal blood loss, the patient was discharged home postoperative on day 1.
Closure of the diaphragm with barbed suture and pexy of the triangular ligament showed great results.