Background

Hiatal hernias are common in bariatric patients. Large hiatal hernias can be challenging in those patients due to laborious dissection of the hiatus and risk for the blood supply to the new pouch. Preoperative endoscopy can usually discriminate for big hiatal hernias but not always. We present a case of a Type IV hiatal hernia in a patient operated for a Roux-n-Y Gastric Bypass (RYGB). A 56 year old man with a preoperative BMI of 44kg/m2 and type 2 diabetes was scheduled for bariatric surgery. Preoperative endoscopy showed a small-medium hiatal hernia with no esophagitis. Patient referred pyrosis. A RYGB was indicated. Intraoperatively a Type IV hiatal hernia with half of the stomach herniated into the mediastinum was found. A careful dissection of the hiatal hernia and reduction of the herniated stomach was performed. 360 degree dissection of the hiatus was carried out with special care of the left gastric artery. The hernia sac was partially removed. Once the anatomy was reconstructed, the hiatus was closed with a running barbed non-absorbable suture. The RYGB was then continued with no incidences. Patient had an uneventful postoperatory and was discharged on postoperative day 2. 3 months after surgery he was doing well, with adequate weight loss, no symptoms of dysphagia nor pyrosis, and no treatment for type 2 diabetes.