A hiatal hernia occurs when the upper part of the stomach pushes upward through the hiatus, the opening in the diaphragm, into the chest cavity. After a sleeve gastrectomy (SG), patients may experience the development or recurrence of this condition. This complication often causes severe gastroesophageal reflux disease (GERD) that is difficult to manage with medication. Treatment requires specialized surgical approaches tailored to the post-bariatric anatomy to repair the defect and resolve persistent symptoms.
Why Hiatal Hernias Occur After Sleeve Gastrectomy
The development of a hiatal hernia after sleeve gastrectomy is linked to changes in gastric pressure dynamics. The sleeve transforms the stomach from a low-pressure reservoir into a narrow, high-pressure tube. This increased pressure exerts upward force on the lower esophagus and the diaphragm’s hiatus, encouraging the stomach remnant to herniate.
The surgical procedure itself can weaken supporting structures around the esophagus. Dissection required to create the sleeve may disrupt the phrenoesophageal ligament, which anchors the stomach to the diaphragm. This ligament laxity, combined with the loss of the stomach’s fundus, increases the risk of herniation.
Chronic acid reflux, common after SG, further exacerbates the issue by causing the esophagus to shorten and retract. This retraction pulls the remaining stomach segment upward through the widened hiatus. Thus, a hiatal hernia in a post-sleeve patient is often both a cause and a consequence of persistent reflux disease.
Identifying the Problem: Symptoms and Diagnosis
A hiatal hernia after sleeve gastrectomy typically presents with symptoms related to severe gastroesophageal reflux. Patients often report persistent heartburn, frequent regurgitation of food or sour liquid, and chest pain that may be mistaken for cardiac issues. Other symptoms include difficulty swallowing (dysphagia), chronic cough, or the sensation of food being stuck.
To confirm the presence and size of the hernia, a doctor utilizes several specific diagnostic tools. An upper GI endoscopy allows for a direct visual assessment of the hiatus and the stomach remnant’s position. This procedure also checks for signs of inflammation or damage to the esophagus lining caused by acid exposure.
A barium swallow study, or esophagram, involves the patient drinking a contrast liquid while X-rays are taken. This provides a dynamic view of the esophagus and the gastric sleeve, visualizing the movement of the stomach through the diaphragm and identifying the dimensions of the herniated tissue. In cases of severe, refractory reflux, specialized tests like esophageal manometry and 24-hour pH monitoring may also be performed.
Surgical Repair Techniques
Repairing a hiatal hernia after sleeve gastrectomy is a specialized procedure, typically performed using minimally invasive laparoscopic techniques. The standard approach involves returning the herniated portion of the stomach from the chest back into the abdominal cavity. Once the stomach is correctly positioned, the surgeon must address the defect in the diaphragm.
The primary method of repair is a crural repair, or cruroplasty, which involves suturing the edges of the diaphragm’s opening (the crura) together to tighten the hiatus around the esophagus. This is accomplished with strong, non-absorbable sutures placed posteriorly to narrow the opening and prevent future herniation. For larger hernias or poor tissue quality, surgical mesh may be used to reinforce the sutured repair and minimize the risk of recurrence.
In patients whose primary issue is not just the hernia but also severe, refractory GERD, a more complex revision may be necessary. This involves converting the existing sleeve gastrectomy into a Roux-en-Y Gastric Bypass (RNYGB). The RNYGB addresses the high-pressure nature of the sleeve and separates the food stream from the majority of the stomach remnant.
The conversion procedure creates a small gastric pouch near the esophagus and reroutes a section of the small intestine to it, significantly reducing the stomach’s exposure to acid reflux. When this revision is performed, the hiatal hernia repair is done simultaneously. This offers the best long-term chance of resolving both the anatomical defect and the severe reflux symptoms, and is reserved for complex cases where a simple hernia repair is unlikely to provide a durable solution.
Post-Repair Expectations and Long-Term Management
Recovery from laparoscopic hiatal hernia repair is generally swift, typically requiring a hospital stay of one to two days. Post-operative discomfort is managed with oral pain medication. Physical activity is restricted for several weeks, meaning no heavy lifting or strenuous exercise. Patients must adhere to a careful diet progression, starting with clear liquids and gradually advancing to soft and then solid foods over several weeks.
The long-term prognosis for symptom resolution is favorable, particularly when the repair includes a conversion to RNYGB for severe reflux. Although the success rate of simple hiatal hernia repair is high, there is a risk of recurrence, making lifestyle modifications important. Patients may need to continue taking proton pump inhibitor (PPI) medication temporarily, aiming to reduce or eliminate its use as symptoms resolve.
Maintaining a healthy weight and avoiding activities that increase abdominal pressure, such as straining or chronic coughing, are necessary to preserve the integrity of the repair. Conversion to a bypass often results in additional weight loss and long-term resolution of the underlying reflux, which is essential for complete recovery and management.