No Absolute Contraindications to Hiatal Hernia Surgery in This Patient
There are no absolute contraindications to hiatal hernia surgery based solely on the patient's psychiatric medications (aripiprazole and mirtazapine) or their schizophrenia with history of catatonia. However, several perioperative considerations require careful management to optimize outcomes and minimize morbidity.
Key Perioperative Psychiatric Considerations
Continuation of Antipsychotic Therapy
The patient's aripiprazole (Abilify) should be continued throughout the perioperative period without interruption. The 2020 APA guidelines emphasize that patients with schizophrenia whose symptoms have improved with an antipsychotic medication must continue treatment to prevent relapse 1. Discontinuation risks acute psychotic decompensation, which would significantly increase perioperative morbidity and mortality.
Catatonia Risk Management
The history of catatonia requires heightened vigilance. Recent evidence demonstrates that aripiprazole can be safely used in catatonic patients and may even be beneficial 2, 3. A 2025 case report showed successful treatment of severe catatonia with combined lorazepam and aripiprazole 3. The 2024 systematic review found aripiprazole had equivocal outcomes in catatonia (neither consistently beneficial nor harmful), making it a reasonable choice to continue perioperatively 2.
Critical perioperative monitoring should include:
- Daily assessment for catatonic signs (mutism, posturing, waxy flexibility, stupor)
- Immediate availability of benzodiazepines (lorazepam) if catatonic symptoms emerge
- Avoidance of first-generation antipsychotics, which showed mostly detrimental outcomes in catatonia 2
Mirtazapine Continuation
Mirtazapine should also be continued. Evidence supports its safety and potential benefit in schizophrenia, with no risk of psychotic exacerbation 4. The 2022 review found mirtazapine may improve negative and cognitive symptoms when added to antipsychotics, with the only large effectiveness study showing decreased hospitalization rates 4.
Medication-Specific Surgical Considerations
Aripiprazole (Abilify) Perioperative Concerns
Orthostatic Hypotension and Falls Risk: The FDA label warns that aripiprazole causes orthostatic hypotension, postural dizziness, and syncope 5. This is particularly relevant for postoperative mobilization. The drug should be used with caution in patients with conditions predisposing to hypotension, including dehydration and hypovolemia—both common perioperatively 5.
Specific perioperative management:
- Aggressive fluid resuscitation to prevent hypovolemia
- Gradual position changes when mobilizing postoperatively
- Fall risk assessment and precautions 5
- Monitor for orthostatic vital sign changes
Dysphagia and Aspiration Risk: The FDA label specifically warns that esophageal dysmotility and aspiration have been associated with antipsychotic use, including aripiprazole 5. This is directly relevant to hiatal hernia surgery, which involves manipulation of the gastroesophageal junction. Aspiration pneumonia is noted as a common cause of morbidity and mortality 5.
Mitigation strategies:
- Maintain NPO status as directed perioperatively
- Elevate head of bed postoperatively
- Careful advancement of diet with swallow assessment if needed
- Monitor for signs of aspiration
Other FDA-Listed Concerns:
- Cognitive and motor impairment: Caution with postoperative pain medications that may compound sedation 5
- Body temperature dysregulation: Monitor core temperature, especially if general anesthesia is prolonged 5
- Seizure risk: Though low (0.1%), use caution with medications that lower seizure threshold 5
Mirtazapine Considerations
While mirtazapine has favorable effects in schizophrenia 4, be aware of:
- Sedation: May compound with anesthetic agents and postoperative opioids
- Metabolic effects: Monitor for hyperglycemia perioperatively when combined with antipsychotics 4
An older 1975 report suggested tricyclic antidepressants may worsen hiatal hernia through anticholinergic effects on the esophageal sphincter 6. However, mirtazapine is not a tricyclic and has a different mechanism of action, making this concern less applicable.
Surgical Technical Considerations
A 2024 case report identified giant hiatal hernia as a relative contraindication to certain endoscopic procedures (EUS-guided hepaticogastrostomy) due to dynamic liver and stomach movement during respiration 7. However, this does not apply to standard hiatal hernia repair surgery, which is the definitive treatment for symptomatic hiatal hernias 8, 9.
The surgical approach should:
- Proceed with laparoscopic repair including crural repair and fundoplication as indicated 8
- Consider partial fundoplication if there are concerns about postoperative dysphagia, given the patient's antipsychotic use and associated dysphagia risk 8
- Ensure comprehensive preoperative assessment including upper endoscopy, manometry, and pH monitoring 8
Common Pitfalls to Avoid
- Do NOT discontinue antipsychotics perioperatively - This risks psychotic relapse and catatonic recurrence, dramatically increasing morbidity
- Do NOT substitute first-generation antipsychotics - These have worse outcomes in catatonia 2
- Do NOT overlook fall risk - Antipsychotics increase fall risk through multiple mechanisms 5
- Do NOT ignore aspiration precautions - Both the underlying hiatal hernia and aripiprazole increase aspiration risk 5
Preoperative Optimization
- Ensure psychiatric stability before elective surgery
- Coordinate with psychiatry for perioperative medication management
- Have benzodiazepines readily available for emergent catatonia treatment
- Optimize volume status given orthostatic hypotension risk
- Complete standard preoperative cardiac and pulmonary assessment per institutional protocols
The decision to proceed with surgery should be based on the severity of hiatal hernia symptoms, risk of complications (obstruction, volvulus, strangulation), and impact on quality of life 8, 9, not on the psychiatric medication regimen, which can be safely managed perioperatively with appropriate precautions.