Bariatric Surgery Education

Preoperative Considerations When You have a Hiatal Hernia

Esophagogastroduodenoscopy, also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract up to the duodenum.

It’s typical to evaluate patients stomach anatomy with an upper GI X-ray series or Esophagogastroduodenoscopy (EGD) also known as endoscopy before bariatric surgery. Findings during this evaluation can alter recommended bariatric procedure choice. Here we review preoperative considerations when a hiatal hernia is found. A hiatal hernia is a condition where a portion of your stomach protrudes through the diaphragm into the chest cavity, leading to various symptoms and potential complications.

Hiatal Hernia Anatomy
Left Image – Normal Anatomy where the junction between the esophagus and stomach (represented by the white dot) is below the diaphragm. Right Image – Hiatal Hernia where the stomach protrudes through diaphragm up into chest with junction between esophagus and stomach (represented by the white dot) is in the chest

Fixing this hernia is likely important for the success of your bariatric surgery. EGD is an excellent screening measure to determine whether a hiatal hernia is present, but a relatively poor judge of the size of the hernia. Based on the hernia seen today, an intraoperative assessment of the size of the hernia will need to be made in the operating room. If the hernia is deemed significant, a hiatal hernia repair would be recommended.

A hiatal hernia occurs when the upper part of your stomach bulges through your diaphragm into your chest cavity. The diaphragm is a large muscle that separates your abdomen from your chest and helps with breathing by contracting and flattening to create a vacuum effect in the lungs.

Many people with a hiatal hernia never have any symptoms. However, a hiatal hernia can cause food and acid to back up into the esophagus, leading to heartburn symptoms. Other symptoms might include belching, difficulty swallowing, chest or abdominal pain, and shortness of breath.

To repair a hiatal hernia, we pull the stomach back into the abdomen and suture the muscles around the esophagus, tightening the diaphragm opening. In some cases, a temporary surgical mesh may reinforce the area. Potential risks, although rare, can include damage to the surrounding structures and recurrence of the hernia in the weeks to years after surgery. It is important to note that repairing the hernia should not significantly affect your time in the hospital or your postoperative care.

Drawing depicts muscles of diaphragm being sewn tight around the esophagus to keep the stomach out of the chest and in the abdomnal cavity

Given the presence of the hiatal hernia, you must carefully consider the best bariatric surgical option. Of course, Sleeve Gastrectomy is a stand-alone bariatric procedure. In addition, Sleeve Gastrectomy is also a part of several of the other bariatric surgeries. Regardless of whether a Sleeve Gastrectomy is performed as a stand-alone procedure or part of another bariatric surgery, the presence of a hiatal hernia is significant when a Sleeve Gastrectomy is involved and requires careful review on your part.

Which bariatric procedures include Sleeve Gastrectomy as a part of the procedure?
1. Sleeve Gastrectomy
2. Single Anastomosis Duodenal Ileal Bypass With Sleeve
3. Duodenal Switch

A bariatric surgery containing Sleeve Gastrectomy in a patient with medium and larger-sized hiatal hernias has a higher recurrence rate, even with hiatal hernia repair. For this reason, you should also consider the Roux-en-Y Gastric Bypass combined with hiatal hernia repair, as it tends to have a lower recurrence rate of hernias and may better control acid reflux symptoms.

When considering Roux-en-Y Gastric Bypass, you should consider your risk for marginal ulcers. If you have a significant risk for marginal ulcers, you should carefully weigh the specific pros and cons of each bariatric procedure with your surgical team to aid in your decision-making.

Suppose you decide to proceed with the Sleeve Gastrectomy and hiatal hernia repair. It would help if you considered adding a procedure known as ligamentum teres cardiopexy, or a falciform ligament wrap. This procedure involves disconnecting the falciform ligament and wrapping it around the upper part of the stomach to provide additional traction on the stomach, helping keep it in the abdomen and potentially reducing the risk of acid reflux post-surgery.

Falciform ligament was useful during development in the uterus but since birth it doesn’t serve a meaningful purpose. It can be repurposed to wrap around the top the Sleeve Gastrectomy to try to prevent hiatal hernia recurrence after repair and hopefully prevent acid reflux

Not repairing the hiatal hernia carries risks, particularly a higher incidence of postoperative acid reflux and potentially other complications such as gastric leak or obstruction. The main goal is to choose the surgical option to provide you with the best long-term outcomes and minimize potential risks.

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