Introduction: The presence of a large hiatal hernia (> 5 cm) is problematic and may preclude successful weight reductive surgery. Primary cruroplasty may be sufficient for smaller diaphragmatic defects, but has been shown to be inadequate for large hiatal hernias. Synthetic mesh is contraindicated when bowel continuity is disrupted, and the use of biologic mesh product has not been fully evaluated.

Methods: A 51 year old female with a history of gastroesophageal reflux disease presented for evaluation for weight reductive surgery. Preoperative EGD and barium swallow were performed which showed a 7 cm hiatal hernia. A laparoscopic primary hiatal hernia repair was performed over a 50 Fr. lighted bougie. A piece of biologic mesh was cut into a keyhole configuration and secured to the diaphragm using staple fixation. After the hiatal hernia repair and mesh reinforcement, a laparoscopic Roux-en-Y gastric bypass (25-mm EEA stapler) was performed.

Results: A postoperative water-soluble contrast study showed complete reduction of the hiatal hernia and no evidence of contrast extravasation or obstruction. The postoperative course was complicated by marginal ulceration, successfully treated with carafate and PPI therapy. Six months from surgery, she has had resolution of her GERD symptoms, and a weight loss of 87 lbs. (41% EBW).

Conclusion: Laparoscopic hiatal hernia repair with biologic mesh reinforcement of the diaphragm is feasible in conjunction with laparoscopic Roux-en-Y gastric bypass and may reduce the recurrence rate of large hiatal hernias.