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.
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.
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.