Hiatal Hernia Recurrence Following Abdominoplasty: A Proposed Algorithm for Screening and Management.

backgroundIncidence of hiatal hernia has been noted to be as high as 20-50% in those undergoing bariatric surgery. Concurrent repair of hiatal hernia at time of bariatric surgery is commonplace to mitigate risk for reintervention secondary to gastroesophageal reflux disease (GERD). Rectus plication during abdominoplasty results in an increase in intra-abdominal pressures. Abdominoplasty has been shown to significantly increase risk of hiatal hernia recurrence following laparoscopic repair. However, despite this known correlation, there are no established algorithms or guidelines for screening and management of hiatal hernias in post-bariatric surgery patients wishing to undergo abdominoplasty. The authors wish to review a case of recurrent hiatal hernia following abdominoplasty and explore the currently available literature to propose an algorithm for screening/management of hiatal hernias, specifically in a bariatric population, prior to abdominoplasty procedure. CASE REPORT: This is a case report of a 40-year-old female with history of obesity and gastroesophageal reflux disease who underwent Roux-en-Y gastric bypass and concurrent hiatal hernia repair with later body contour surgery in the form of abdominoplasty with rectus plication. Following abdominoplasty, the patient developed intractable reflux symptoms and PO intolerance. Esophagogastroduodenoscopy demonstrated recurrent hiatal hernia which was not noted prior to abdominoplasty.

conclusionThe authors recommend eliciting history of GERD and hiatal hernia in bariatric patients prior to abdominoplasty to predict and mitigate possible postoperative complications. Additional studies are needed to determine at what threshold hiatal hernia repair should be prophylactically performed prior to abdominoplasty; whether intraoperative monitoring of peak airway or bladder pressures may be used to tailor the extent of fascial plication; or whether fascial plication should be abandoned all together in high-risk patients. For now, plastic and minimally invasive surgeons must be aware of the possible clinical implications of fascial plication in a bariatric patient with hiatal hernia to counsel patients accordingly and monitor for postoperative signs of GERD or recurrent hiatal hernia.