Routine hiatal hernia repair in laparoscopic gastric banding.

Laparoscopic gastric banding is now well established as an effective means of obtaining safe, healthy weight loss in the morbidly obese patient population. The procedure has evolved over the years to minimize complications and optimize results. Preoperative patient evaluation includes upper endoscopy to assess the baseline integrity of the stomach and rule out pathology. Upper endoscopy fails to demonstrate the majority of small hiatal hernias in these patients preoperatively. Hiatal hernias are grossly underappreciated in patients with morbid obesity due to the presence of a large distal esophageal fat pad. With post-operative internal weight loss, a small crural defect can become relatively large in a short amount of time. Performing gastric banding without dissecting and repairing the hiatal hernia can lead to incorrect positioning of the gastric band, which is associated with poor weight loss, chronic reflux, and increased complications. Concomitant hiatal hernia repair is felt by the authors to be a necessary component for the correct placement of the gastric band device, which, in turn, provides excellent long-term results to our patients.