Background

Morbid obesity is associated with an increased rate of hiatal and paraesophageal hernias (PEH). Concomitant repair at the time of Roux-En-Y gastric bypass is technically feasible, safe, and lowers recurrence rates; however, the ideal operative management remains controversial. The use of reinforcing mesh may further lower recurrence rates in the bariatric patient population. The patient is a 49 year-old female with a history of morbid obesity (BMI 42) and long-standing reflux with dysphagia. Preoperative endoscopy was notable for esophagitis and a moderate-sized PEH. Esophageal manometry revealed impaired esophageal motility with incomplete relaxation of the lower esophageal sphincter. Due to the patient’s significant reflux symptoms, a laparoscopic Roux-En-Y gastric bypass and PEH repair with mesh was recommended. This video demonstrates the techniques utilized.

Methods

The procedure began with creation of the biliopancreatic and Roux limbs with an end-to-side jejunojejunostomy. A type III paraesophageal hernia was identified after advancement of the Roux limb toward the stomach. The PEH was circumferentially mobilized and reduced. A 2 cm intra-abdominal esophagus was achieved without disruption of the peritoneum overlying the crura. A retroesophageal window was created and the hernia sac was excised. The gastric pouch was then created, followed by completion of a gastrojejunostomy. The PEH repair was then undertaken with primary approximation of the crura and reinforcement with an onlay biosynthetic mesh.

Results

The patient’s postoperative course was uneventful and at one month post-op, the patient’s weight loss totalled 23 lbs with resolution of reflux and dysphagia symptoms.