Clinical Scorecard: Bikini-Line Approach for Hiatal Hernia Repair During Sleeve Gastrectomy

At a Glance

Key Highlights

• Hiatal hernia is common in obese patients (23–52.6%) and an independent risk factor for GERD post-sleeve gastrectomy.
• Bikini-Line Sleeve Gastrectomy (BLSG) places trocars along the lower abdomen to conceal scars within the bikini line.
• Bikini-Line Hiatal Hernia Repair (BLHHR) allows safe and feasible concurrent hiatal hernia repair through the same access points.

Guideline-Based Recommendations

Diagnosis

• Perform thorough intraoperative inspection of the gastroesophageal junction and diaphragmatic hiatus to identify hiatal hernia.
• Use upper gastrointestinal endoscopy preoperatively and at 6 months postoperatively to assess hiatal hernia and GERD.

Management

• Perform concurrent laparoscopic hiatal hernia repair during sleeve gastrectomy to reduce postoperative reflux risk.
• Use bikini-line trocar placement for improved cosmetic outcomes without compromising surgical safety.
• Exclude patients with hiatal hernia > 3 cm, BMI > 55 kg/m2, or unfavorable anatomical distances to ensure procedural safety.

Monitoring & Follow-up

• Evaluate postoperative GERD symptoms using a simplified clinical classification system at follow-up.
• Assess scar satisfaction using validated Scar Assessment Questionnaire subscales.
• Monitor weight loss as percentage of excess weight loss (%EWL) and resolution of comorbidities such as diabetes and hypertension.

Risks

• Potential technical challenges in patients with large hiatal hernias or high BMI.
• Exclusion of patients with extensive lower abdominal adhesions or unfavorable anatomical measurements to avoid ergonomic difficulties.

Patient & Prescribing Data

Obese patients undergoing laparoscopic sleeve gastrectomy with concurrent hiatal hernia ≤ 3 cm

Concurrent hiatal hernia repair via bikini-line approach is feasible, safe, and improves cosmetic outcomes without compromising surgical efficacy.

Clinical Best Practices

• Careful patient selection based on BMI, hernia size, and anatomical measurements to optimize surgical ergonomics and safety.
• Standardized perioperative protocols and operative techniques performed by experienced surgeons.
• Use of modified patient positioning (modified split-leg with left leg straight) to facilitate suturing during repair.
• Comprehensive preoperative and postoperative evaluation of GERD symptoms and scar satisfaction.

References

• International Sleeve Gastrectomy Expert Panel Consensus Statement
• Daes et al. on hiatal hernia incidence in LSG patients
• Scar Assessment Questionnaire (PSAQ) validation