Overview

Definition:
-A hiatal hernia occurs when the upper part of the stomach bulges through the diaphragm into the chest cavity
-In bariatric patients, this condition is often associated with morbid obesity and presents a unique surgical challenge due to anatomical changes and increased surgical risks.
Epidemiology:
-Hiatal hernias are common, affecting 10-20% of the general population
-They are more prevalent in individuals with obesity, older age, and certain genetic predispositions
-In the bariatric surgery population, the incidence can be significantly higher, with studies reporting 40-75% of patients undergoing bariatric procedures having a hiatal hernia.
Clinical Significance:
-Undiagnosed or unrepaired hiatal hernias can lead to severe gastroesophageal reflux disease (GERD), esophagitis, strictures, Barrett's esophagus, and even esophageal cancer
-In bariatric surgery, a significant hiatal hernia can compromise the success of weight loss surgery, leading to persistent symptoms, malnutrition, and the need for revision surgery.

Indications For Repair

Gastroesophageal Reflux Disease: Persistent, symptomatic GERD refractory to medical management, including heartburn, regurgitation, dysphagia, and chest pain.
Large Or Symptomatic Hernias: Large paraesophageal hernias that cause gastric outlet obstruction, early satiety, postprandial fullness, or pose a risk of strangulation or torsion.
Associated With Bariatric Surgery: The presence of a significant hiatal hernia identified during the preoperative evaluation or intraoperatively during bariatric surgery (e.g., sleeve gastrectomy, gastric bypass) that can negatively impact the outcome of the primary bariatric procedure.
Esophageal Complications: Esophagitis, peptic strictures, Barrett's esophagus, or recurrent aspiration pneumonia secondary to the hiatal hernia and GERD.

Preoperative Evaluation And Preparation

History And Physical Examination:
-Detailed history of GERD symptoms, nutritional status, and comorbidities
-Physical exam focusing on abdominal girth, signs of malnutrition, and cardiopulmonary status.
Endoscopy: Upper gastrointestinal endoscopy is crucial to assess the size of the hernia, grade of esophagitis, presence of strictures, Barrett's esophagus, and rule out other upper GI pathologies.
Barium Swallow: Barium swallow can delineate the anatomy, confirm the diagnosis of hiatal hernia, and assess its size and type, especially paraesophageal hernias.
Manometry And Ph Monitoring: Esophageal manometry to assess motility and 24-hour pH monitoring to objectively document the severity of reflux, particularly in patients with atypical symptoms or before anti-reflux surgery.
Nutritional Assessment: Thorough nutritional assessment by a dietitian to identify deficiencies and plan for preoperative optimization and postoperative dietary management.
Anesthetic Considerations: Careful preoperative assessment by the anesthesiologist due to increased risks of aspiration, difficult intubation, and cardiorespiratory compromise in obese patients.

Surgical Management

Approach:
-Laparoscopic approach is the preferred method due to faster recovery, reduced pain, and shorter hospital stay
-Open surgery may be considered in select cases.
Hernia Reduction And Sac Excision:
-Careful dissection and reduction of the herniated stomach and surrounding organs back into the abdominal cavity
-The sac peritoneum is then dissected and excised.
Crural Repair:
-The diaphragmatic crura are identified and approximated using non-absorbable sutures to narrow the hiatus
-This is a critical step to prevent reherniation.
Fundoplication:
-A 360-degree Nissen fundoplication is commonly performed to reinforce the repair and restore the anti-reflux barrier
-Partial fundoplications (e.g., Toupet) may be considered in specific cases.
Gastropexy: In certain cases, especially with large hernias or significant laxity, a gastropexy may be added to further stabilize the stomach.
Intraoperative Considerations:
-Meticulous dissection to avoid injury to adjacent organs like the spleen, esophagus, and vagal nerves
-Careful attention to hemostasis
-The role of mesh in crural repair is controversial and generally avoided due to infection risk.

Postoperative Care And Follow Up

Dietary Advancement: Gradual progression from clear liquids to pureed, soft, and then regular diet as tolerated, with an emphasis on small, frequent meals.
Pain Management: Adequate analgesia to manage incisional pain and abdominal discomfort.
Early Mobilization: Encourage early ambulation to prevent venous thromboembolism and promote recovery.
Monitoring For Complications: Close monitoring for signs of bleeding, infection, gastric outlet obstruction, dysphagia, and leaks.
Long Term Follow Up: Regular follow-up with the surgical team and dietitian to assess symptom resolution, weight loss progress, nutritional status, and address any emerging issues.

Complications

Early Complications:
-Bleeding
-infection
-wound dehiscence
-gastric injury
-esophageal perforation
-splenic injury
-deep vein thrombosis
-pulmonary embolism
-anastomotic leak (rare with fundoplication alone).
Late Complications:
-Recurrent hiatal hernia
-dysphagia
-dumping syndrome (especially after concomitant bypass)
-gas bloat syndrome
-marginal ulcers
-nutritional deficiencies
-weight regain
-persistent GERD symptoms.
Prevention Strategies: Meticulous surgical technique, appropriate selection of patients, judicious use of sutures for crural repair, prompt management of complications, and adherence to postoperative dietary guidelines and follow-up.

Key Points

Exam Focus:
-Understand the high incidence of hiatal hernias in obese patients undergoing bariatric surgery
-Recognize indications for repair, the importance of preoperative evaluation, and key steps in laparoscopic Nissen fundoplication.
Clinical Pearls:
-Always consider a hiatal hernia when evaluating GERD in an obese patient
-Intraoperative identification and repair of even small hernias are crucial to prevent long-term complications and ensure bariatric surgery success.
Common Mistakes:
-Underestimating the size of the hernia
-inadequate crural repair leading to recurrence
-aggressive dissection causing injury to surrounding structures
-failing to address severe GERD preoperatively, impacting bariatric outcomes.