Robotic Ligamentum Teres Cardiopexy with Hiatal Hernia Repair for GERD following Longitudinal Sleeve Gastrectomy

Patients who undergo longitudinal sleeve gastrectomy (LSG) may develop de novo or worsening of existing gastroesophageal reflux (GERD) symptoms, which include postprandial retrosternal burning, food refluxing, or dysphagia. Often patients with GERD following LSG present with a concomitant hiatal hernia. Workup serves to characterize a patient’s GERD disease burden by way of fluoroscopic upper gastrointestinal (UGI) series, pH studies, manometry, or esophagogastroduodenoscopy (EGD). Treatment first involves medical management with lifestyle modifications followed by use of pump inhibitors (PPIs) or Histamine H2-receptor antagonists (H2 Blockers or H2B). If GERD symptoms remain intractable to medical management, surgical intervention can be pursued. Historically patients would undergo a conversion to a Roux-en-Y gastric bypass (RYGB). New data demonstrate comparable outcomes regarding GERD symptoms and improvements in anti-reflux medication use in patients status-post LSG who undergo ligamentum teres cardiopexy with hiatal hernia repair. Here, we describe a robotic ligamentum teres cardiopexy with hiatal hernia repair in an adult patient who previously underwent LSG and was experiencing intractable GERD symptoms despite lifestyle modification and optimization on anti-reflux medications.

Nearly half of patients have baseline gastroesophageal reflux (GERD) symptoms prior to undergoing bariatric surgery, with several patients have worsening or new onset of reflux symptoms following longitudinal sleeve gastrectomy (LSG).¹ Historically, conversion to Roux-en-Y gastric bypass (RYGB) has been considered the surgical treatment for GERD management post-LSG. The use of ligamentum teres cardiopexy with concomitant hiatal hernia repair (LT cardiopexy) presents an alternative surgical option for improvement or resolution of GERD symptoms.

Here we present a 48-year-old Spanish-speaking female with a past medical history significant for GERD, anxiety, and obesity who was status-post robotic sleeve gastrectomy and hiatal hernia repair in July 2022. She had a subsequent 88 lbs weight loss with BMI decreasing from 43.2 kg/m² to 28.6 kg/m², but experienced worsening of her preoperative GERD symptoms. The patient had GERD prior to LSG, which remained refractory to twice daily 20 mg omeprazole usage despite significant weight loss, dietary changes, and hiatal hernia repair at the time of index bariatric surgery. She underwent  fluoroscopic upper gastrointestinal (UGI) series that identified a recurrent hiatal hernia with spontaneous moderate GERD to the level of the distal esophagus. No EGD, manometry, or pH studies were performed.

Options of operative interventions were reviewed with the patient, who opted to pursue minimally-invasive ligamentum teres cardiopexy with hernia repair (LT cardiopexy).

The patient had no other prior abdominal surgeries aside from what is listed above. Her medications included atorvastatin, biotin, calcium carbonate-vitamin D3 tablet, cyanocobalamin tablet, omeprazole, multivitamin. She is a non-smoker and has no known drug allergies. There are no relevant laboratory results to report.

Physical exam revealed a well-nourished, healthy-appearing female in no apparent distress with normal vital signs. Her BMI was 28.6 kg/m². Abdomen was of overweight habitus, soft, non-distended, non-tender in all quadrants with no palpable masses.

Pre-existing GERD is very common in bariatric surgical patients, with nearly half of patients having GERD symptoms before undergoing any surgical intervention.¹ GERD in this patient population develops for a variety of reasons including dietary choices and higher adiposity causing increased intra-abdominal and intra-gastric pressure impacting the gastroesophageal junction (GEJ).^2,3 One study found that approximately 9% of patients have worsening GERD symptoms following LSG, and 10% developed new onset GERD.¹ Reasons for this have been speculated to include anatomic changes to the stomach with altered angle of His and resection of the sling fibers in the distal part of the lower esophageal sphincter, which result in low esophageal-sphincter pressure and de novo or recurrence of hiatal hernias.^4-8

Fluoroscopic UGI series provides real-time view of a patient’s anatomy visualizing barium traveling through the esophagus, stomach, and duodenum as a person drinks. This allows radiologists to visualize contrast refluxing and anatomic abnormalities such as hiatal hernias. Additional studies to evaluate the degree of GERD disease burden include pH studies, manometry, or EGD. A CT scan of the abdomen and pelvis can also identify the presence of a hiatal hernia. This patient underwent UGI series in August 2023 (approximately one year following sleeve gastrectomy), which demonstrated appropriate post sleeve gastrectomy anatomy but recurrence of her hiatal hernia.

Patients who present with GERD symptoms following LSG should first be managed medically in a stepwise fashion, starting with diet change and weight loss. Following this, the addition of medications can be tried, which includes monotherapy or concomitant use of pump inhibitors (PPIs) or Histamine H2-receptor antagonists (H2 Blockers or H2B). If symptoms persist then surgical interventions may be pursued. Compared to the general population, patients who have undergone  LSG are not typically candidates for a fundoplication procedure due to loss of natural stomach fundus redundancy utilized in a fundoplication wrap. As such, the surgical intervention typically offered is conversion to a Roux-en-Y gastric bypass (RYGB). Other procedures such as magnetic sphincter augmentation lack long-term safety data, and endoscopic approaches have undetermined longitudinal benefits. The alternative surgical intervention of ligamentum teres cardiopexy with hiatal hernia repair demonstrated in this video is a newer technique available to most patients following LSG with intractable GERD who do not wish to undergo conversion to RYGB.

This patient had undergone a LSG in 2022 and had persistent GERD symptoms despite lifestyle modification, significant weight loss, and being on a long-term PPI. Conversion to gastric bypass was offered; however, the patient did not wish to pursue this due to added long term risks associated with RYGB, and the patient was not interested in additional weight loss. She had undergone fluoroscopic UGI series, which demonstrated recurrence of her hiatal hernia, likely contributing to her symptoms. Magnetic sphincter augmentation was not offered as it is not performed at our institution and would not have addressed the patient’s hiatal hernia. Given her intractable GERD and personal preferences, a hiatal hernia repair with LT cardiopexy was indicated to reduce her hiatal hernia and provide reinforcement at the GEJ. The surgeon chose a robotic approach due to surgeon preference.

In the bariatric world, the risk of developing GERD following LSG is well established. Dupree et al. found that 9% of patients following LSG developed worsening of their GERD symptoms compared to 2.2% who had undergone a RYGB.¹ For patients with intractable GERD who had previously undergone LSG, the mainstay surgical treatment has been conversion to RYGB.  Additionally, some patients may opt to pursue RYGB conversion not only for reflux symptom improvement, but for the added weight loss that would be anticipated postoperatively. However, despite its benefits, a RYGB comes with a multitude of short- and long-term risks including but not limited to: marginal ulceration, internal hernias, dumping syndrome, and nutritional deficiencies.⁹ Furthermore, newer longitudinal data has demonstrated the development of reflux and dysmotility disorders years following RYGB, for unclear etiologies, hinting that the improvement in GERD symptoms may not be lifelong.¹⁰ Minimally-invasive LT cardiopexy with hiatal hernia repair presents a viable surgical alternative to patients with GERD following LSG who do not wish to undergo RYGB conversion.

LT cardiopexy is performed via minimally-invasive approach and the steps are equivalent whether being performed laparoscopically or robotically. Patient positioning and port placement requires careful consideration and planning to perform adequate exposure and reach of instruments; the patient is placed in reverse Trendelenburg with slight left up tilt throughout the procedure. Pneumoperitoneum is induced typically via the Veress technique at Palmer’s point. A camera trocar is placed in the supraumbilical region. Other port sites are in the left mid-abdomen trocar, and both right and left mid-quadrant. Instruments utilized throughout the procedure included 30-degree scope, monopolar scissor, vessel sealer, Cadiere grasper, fenestrated bipolar grasper, and needle driver. If there is presence of a hiatal hernia, as in this case, then a complete circumferential dissection along the esophagus and the bilateral crura is achieved until 3 cm of intra-abdominal esophagus is mobilized. The ligamentum teres is mobilized from the anterior abdominal wall dissecting towards the major fissure of the liver taking care to preserve as much length as possible. Intraoperative endoscopy was performed in this case to identify the GE juncture, which was below the level of the hiatus as well as confirming the gastric sleeve anatomy was straight without evidence of redundancy or angulation. The hiatus is repaired by reapproximating the crura using two Ethibond mattress sutures and utilizing Bio-A mesh pledgets for reinforcement. Hiatus closure is then typically reinforced with mesh; in this case, a preformed U-shaped Bio-A mesh was placed along the posterior and bilateral crura. The ligamentum teres is delivered posterior to the esophagus at the level of the GE juncture and sutured to the stomach, and occasionally the crus. The remainder of the ligamentum teres is wrapped 270 degrees around the distal left esophagus and sutured to the anterior stomach cardia just distal to the GE junction. Of note, Mackey et al. found that among 60 patients status post sleeve gastrectomy undergoing ligamentum teres cardiopexy, 100% had a hiatal hernia.¹¹ Therefore, surgeons performing ligamentum cardiopexy should be prepared to perform a hiatal hernia repair as a part of the cardiopexy procedure.

Techniques of cardiopexy “technique du collet” was first proposed by Pedinielli for hiatal hernia management. In 1964 this was adapted by Rampal et al. to specifically utilize the ligamentum teres for GE juncture reinforcement for hiatal hernia management.^12,13 While the exact physiological mechanism by which the ligamentum teres (LT) cardiopexy counteracts GERD symptoms is unknown, it is thought to serve in a similar function to fundoplication. By securing the LT below the hiatus to the stomach and occasionally the crus, it provides GEJ reinforcement and helps anchor the gastric sleeve in its anatomic position. Research outlining the utilization of the ligamentum teres cardiopexy for the bariatric population as a technique to reinforce the GEJ following hiatal hernia repair to help with GERD symptoms had not evolved until recently.

Huynh et al. demonstrated a 62% decrease in antisecretory medication requirements in patients who had undergone RYGB.¹⁴ Conversely, a single-site study by Mackey et al. investigated the effects of a hiatal hernia repair with LT cardiopexy on GERD symptoms and found 81% of patients were able to decrease the dose or stop their antisecretory medications (H2B or PPI) at 1 year post-op.¹¹ Other single-site studies have demonstrated between 80.0–86.6% of patients had improvement or resolution of their GERD symptoms following LT cardiopexy.^4,15 These patient additionally had decreased postoperative complications when compared to patients who underwent RYGB conversion. A recent abstract presented at the American Society for Metabolic and Bariatric Surgery Summer 2024 meeting found that more patients had a decrease in PPI usage at 1 year following LT cardiopexy compared to patients who underwent RYGB conversion for intractable GERD following LSG.¹⁶ From a safety profile, Mackey et al. identified reoperation rates of 3.4% for patients who underwent LT cardiopexy compared to published numbers of 6.7% who underwent conversion to RYGB.¹¹ Additionally, length of stay is approximately 1.3–1.5 days for a LT cardiopexy. While longitudinal data is limited, we believe that minimally-invasive hiatal hernia repair with LT cardiopexy presents a safe alternative to RYGB conversion for patients with intractable GERD following LSG.

GERD symptoms are prevalent in the bariatric population, with many experiencing the development of symptoms, or worsening of symptoms following LSG that persists despite lifestyle modifications and antisecretory medications. Minimally-invasive hiatal hernia repair with LT cardiopexy is a safe, effective surgical option for improving GERD symptoms; however, further research is encouraged to evaluate its effectiveness.

This surgery was performed using the DaVinci Xi robotic platform (Intuitive Surgical, Sunnyvale, CA). Hiatus was closed utilizing Bio-A Mesh (GORE Medical, Newark, DE).

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.