Abstract
Obesity is a multifactorial disease with numerous comorbidities, including gastroesophageal reflux disease (GERD) and hiatal hernia. Roux-en-Y gastric bypass (RYGB) remains one of the most effective surgical interventions for sustained weight loss, while also relieving GERD through various mechanisms. This case report describes the treatment of a patient with a history of obesity, GERD, and no reported prior foregut operations, who sought surgical weight loss through RYGB but was found intraoperatively to have had a prior hiatal hernia repair and fundoplication, emphasizing the importance of thorough preoperative evaluation and intraoperative problem solving to address obesity and its comorbidities. A 44-year-old man with BMI 42.65, GERD and two laparoscopic ventral hernia repairs presented to bariatric clinic seeking surgical weight loss after failing to achieve sustained weight loss through a combination of reduced calorie diet, physical exercise, and medications. Preoperative EGD noted a small hiatal hernia but was otherwise normal. Given his obesity, GERD, and hiatal hernia, robotic RYGB with possible hiatal hernia repair was recommended. Intraoperatively, a large ventral hernia with incarcerated omentum and small bowel was encountered, along with a previous hiatal hernia repair and loosely approximated fundoplication. He underwent robotic RYGB, primary repair of recurrent incisional hernia, and takedown of prior fundoplication. The patient recovered appropriately and was discharged on post-operative day one on bariatric full liquid diet. At his one-week follow up visit, patient reported 5 pound weight loss and denied reflux symptoms. This case underscores the importance of meticulous preoperative evaluation and intraoperative flexibility. The presence of a hernia with incarcerated omentum and small bowel and unexpected fundoplication demanded intraoperative modification to the surgical plan. Fortunately, the robotic approach facilitated a comprehensive solution for the patient’s obesity, altered foregut anatomy, and GERD.