What are the considerations for hiatal hernia repair in an obese patient with gastroesophageal reflux disease (GERD)?

From the Guidelines

Hiatal hernia repair in obese patients with GERD should be approached with caution, prioritizing weight loss and a multidisciplinary evaluation to minimize complications and optimize outcomes. The management of hiatal hernia in obese patients is complex, and the evidence suggests that a laparoscopic approach may be feasible and safer, with shorter hospital stays and less morbidity compared to open surgery 1. However, the data on robotic surgery for hiatal hernia repair is limited, and its use should be considered by experienced surgical and nursing teams in clinically stable patients 1.

When considering hiatal hernia repair in obese patients with GERD, the following key points should be taken into account:

• Weight loss before surgery is crucial, with a target BMI below 35 kg/m² when possible, to reduce technical difficulty and complication rates
• A preoperative evaluation should include endoscopy, barium swallow, esophageal manometry, and pH monitoring to confirm diagnosis and rule out other conditions
• The preferred surgical approach is laparoscopic Nissen fundoplication with hiatal hernia repair, which involves reducing the hernia, closing the hiatal defect, and creating a 360-degree gastric wrap around the lower esophagus
• Mesh reinforcement may be necessary for large hernias (>5 cm) to reduce recurrence risk
• Postoperatively, patients should follow a graduated diet, avoid heavy lifting, and take acid-suppressing medications like proton pump inhibitors

For severely obese patients (BMI >40), bariatric surgery combined with hiatal hernia repair may provide better long-term outcomes by addressing both conditions simultaneously. This approach can help reduce intra-abdominal pressure, which contributes to both GERD symptoms and hiatal hernia formation, making appropriate surgical planning essential for successful outcomes. The use of gastrostomy and PEG may also be considered in patients with difficulties in oral intake, as they can provide fixation of the anterior stomach to the abdominal wall and relieve symptoms 1.

From the Research

Considerations for Hiatal Hernia Repair in Obese Patients with GERD

• The prevalence of hiatal hernias in morbidly obese patients is significant, with one study finding a prevalence of 37.0% based on preoperative upper GI contrast studies 2.
• Obese patients with large hiatal hernias and GERD may benefit from antireflux gastric bypass (ARGB) surgery, which has been shown to have similar GERD resolution rates and lower hernia recurrence rates compared to fundoplication 3.
• Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is an effective procedure for controlling symptoms and complications of gastroesophageal reflux in morbidly obese patients with hiatal hernias 4.
• Mesh cruroplasty has been proposed as a technique for repairing large hiatus hernias, with studies showing low recurrence rates and no mesh-related complications on long-term follow-up 5.
• Aggressive management of hiatal weakness during laparoscopic sleeve gastrectomy (SG) may result in improved GERD symptoms, with one study finding significant reductions in heartburn frequency and severity 6.

Surgical Options

• Antireflux gastric bypass (ARGB) surgery may be a suitable option for obese patients with large hiatal hernias and GERD 3.
• Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a commonly performed procedure for morbidly obese patients with hiatal hernias 4.
• Laparoscopic sleeve gastrectomy (SG) with aggressive management of hiatal weakness may also be an effective option for improving GERD symptoms 6.
• Mesh cruroplasty may be used to repair large hiatus hernias, with low recurrence rates and no mesh-related complications on long-term follow-up 5.

Patient Outcomes

• Obese patients with large hiatal hernias and GERD may experience improved symptoms and quality of life after undergoing surgical repair 3, 4, 6.
• Weight loss and excess body weight loss may be superior with ARGB surgery compared to fundoplication 3.
• Recurrence rates may be lower with ARGB surgery and mesh cruroplasty compared to other surgical techniques 3, 5.