NEW CONCEPTS Initial Experience with Laparoscopic Crural Closure in the Management of Hiatal Hernia in Obese Patients Undergoing Sleeve Gastrectomy Emanuele Soricelli & Giovanni Casella & Mario Rizzello & Benedetto Calì & Giorgio Alessandri & Nicola Basso Received: 8 August 2009 / Accepted: 1 December 2009 / Published online: 5 January 2010 # Springer Science+Business Media, LLC 2009 Abstract Background The prevalence of gastroesophageal reflux disease (GERD) and/or hiatal hernia (HH) is significantly increased in morbidly obese patients. Laparoscopic bariatric procedures such as gastric banding (LGB) and Roux-en-Y gastric bypass have been shown to improve both obesity and reflux symptoms. The aim of this paper is to evaluate the effectiveness of laparoscopic sleeve gastrectomy (LSG) and hiatal hernia repair (HHR) for the treatment of obesity complicated by HH. Methods From October 2008, six patients underwent HHR in addition to LSG. Clinical outcomes have been evaluated in terms of GERD symptoms improvement or resolution, interruption of antireflux medication, and X-ray evidence of HH recurrence. Results Symptomatic HH was diagnosed preoperatively in four patients. In two additional patients, HH was asymptom- atic and it was diagnosed intraoperatively. Prosthetic rein- forcement of crural closure was performed in two symptomatic cases with a HH >5 cm. Mortality was nil and no complications occurred. After a mean follow-up of 4 months, GERD symptoms resolution occurred in three patients, while the other patient reported an improvement of reflux. Body mass index had fallen from 43.4 to 36.2 kg/m 2 . A small recurrence in the patient with persistence of reflux symptoms has been radiologically reported. Conclusions Laparoscopic crural closure in addition to LSG could represent a valuable option for the synchronous management of morbid obesity and HH, providing good outcomes in terms of weight loss and GERD symptoms control. Keywords Morbid obesity . GERD . Hiatal hernia . Laparoscopy . Sleeve gastrectomy . Mesh Introduction Gastroesophageal reflux disease (GERD) and/or hiatal hernia (HH) is one of the most common disorders affecting the upper gastrointestinal tract with a prevalence rate of about 20% in the general population. Obesity has been proven to be a significant independent risk factor for the development of GERD and/or HH: about 50–70% of patients undergoing bariatric surgery for morbid obesity have a symptomatic reflux [1–4], while symptomatic HH is present in 15% of patients with a body mass index (BMI) >35 kg/m 2 [5, 6]. GERD and HH are associated with increased BMI. Laparoscopic antireflux surgery (LARS) is considered the gold standard for the treatment of GERD and/or HH [7–11]. A prosthetic-reinforced hiatoplasty seems to reduce significant- ly the risk for postoperative disruption of hiatal repair [7, 11– 16]. Nevertheless recent studies have demonstrated that obesity plays an adverse role on long-term clinical outcomes of LARS [17–19]. As a result, bariatric procedures as laparoscopic gastric banding (LGB) with hiatal hernia repair (HHR) [20–24] and laparoscopic Roux-en-Y gastric bypass (LRYGBP) [25–30] have been proposed by several authors for the synchronous treatment of morbid obesity and GERD with or without HH, providing good results in terms of excess weight loss and reflux symptoms improvement. The authors have no conflict of interest. E. Soricelli : G. Casella : M. Rizzello : B. Calì : G. Alessandri : N. Basso (*) Surgical-Medical Department for Digestive Diseases, Policlinico “Umberto I”, University “Sapienza”, Viale del Policlinico, 00161 Rome, Italy e-mail: nicola.basso@uniroma1.it OBES SURG (2010) 20:1149–1153 DOI 10.1007/s11695-009-0056-8