The Results of Hiatal Hernia not Amended During Gastric Banding-A Case Report and the Conclusions Stemming from it

Introduction: Hiatal hernia is frequent in patients undergoing bariatric surgery [1]. There is evidence that laparoscopic gastric banding is associated with deterioration of GERD, however, the treatment of a hiatal hernia accidentally discovered during a LGB is still under debate. We would like to use the current case report to shed some light upon the decision not to close a hiatal hernia discovered accidentally during Lap band, and its grave consequences. Patient description: A 36 old female, with a known LGB, was admitted to the Urology ward due to suspected nephrolithiasis and Left flank pain. Deterioration in her status and worsening of the LUQ pain has led to a CT with subsequent drain insertion due to a suspected effusion. A follow up CT showed the stomach in the left hemithorax, with the drain inserted in the upper border of the stomach. The patient was taken to the OR, and there a multidisciplinary team of general and cardiothoracic surgeons operated upon her. In the operation a left thoracotomy was done to enable the reduction of the stomach back to the abdomen and a thorough drainage of the left chest. After that, in a formal laparotomy a sleeve gastrectomy was done due to necrosis of the greater curvature. An esophagostomy was performed to enable diversion of esophageal content from the stomach. Discussion and conclusions: Many changes have occurred in the bariatric field since the 1990’s when hiatal hernia was considered a contraindication for LAGB. But, a change of paradigm has occurred, and just like our patient has shown, not operating upon a hiatal hernia during LAGB is extremely dangerous for the patient. From this stems only one conclusion If one encounters a hiatal band during a LAGB procedure, be it a primary or revisional one, one has to fix this defect or else endanger his patient unnecessarily. enlarged hiatus). Incidence of hiatal hernias increases with age, and other risk factors like obesity, frequent vomiting or coughing, smoking and pregnancy, all these even more frequent in the bariatric patients [1,2]. It has been long debated if patients with hiatal hernia should be operated upon, and when to operate upon these patients was and still is controversial [3,4]. The advocates state that patients with evidence of severe esophageal injury (ulcer, stricture or Barrett’s mucosa) and incomplete resolution of symptoms or relapses while on medical therapy are appropriate candidates to consider for operative intervention [5]. Other patients with a long duration of symptoms, or those in whom symptoms persist at a young age are also considered for operative treatment initially. In these patients, operative therapy is considered an alternative to medical therapy rather than a treatment of last resort. This is all well known, but what if the patient does not come to surgery due to hiatal hernia symptoms? One must remember that a hiatal hernia is present in up to 15-50% of the patients undergoing bariatric surgery [1]. Thus, what should we do with an accidental finding of a hiatal hernia found during a bariatric procedure? This might be the case in Gastric banding (LGB), in which we have an excellent view of the diaphragm. What should we do in a hiatal hernia accidentally discovered during a LGB? Should we refrain from operating upon it? We would like to use the current case report to shed some light upon the decision not to close such a hiatal hernia discovered accidentally during a Lap band, and its grave consequences.