Dr Sorin Cimpean, Digestive Surgeon

08/03/2026

The goal of the hiatal closure is to restore normal anatomy, reinforce the lower esophageal sphincter, and prevent stomach herniation.

-Studies suggest that V-Loc sutures provide comparable strength to traditional sutures with faster operative times. A 2023 study on laparoscopic hiatal hernia repair noted reduced suturing time (by ~15%) with V-Loc compared to interrupted sutures, with similar recurrence rates (~5-10% at 5 years).

-Advantages:
Faster closure compared to interrupted sutures.
Reduced risk of suture failure due to even tension distribution.
Knotless design minimizes foreign body reaction.

-Progrip reinforcement present lower hernia recurrence in selected cases; self-fixating design simplifies placement laparoscopically or robotically. Beware the risk of erosion!!! For that reason the mesh I placed is not in contact with the oesophagus and well covered by the gastric valve.

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04/03/2026

Here is a patient sent by the cardiologist for postprandial cardiac arrhythmia.

There's a recognized association between hiatal hernia (HH) and certain cardiac arrhythmias, particularly atrial fibrillation (AF), though it's not common and often linked to larger hernias.

The most frequently reported arrhythmia is atrial fibrillation (AF), including new-onset or paroxysmal AF. Studies and case reports show people with HH (particularly larger ones) have a higher prevalence of AF compared to the general population. One large study found AF in about 7.1% of HH patients, with dramatically higher rates (17–19 times higher) in younger patients (3 cm were associated with higher incidence.

Other arrhythmias have been reported less commonly, including:
Atrial flutter
Supraventricular tachycardia
Premature ventricular contractions (PVCs, sometimes in bigeminy)
Bradycardia or sinus bradycardia
Rarely, more severe issues like ventricular standstill in extreme compression cases

The main proposed mechanism is mechanical compression or irritation of the heart (especially the left atrium) by the herniated stomach, which sits directly behind the heart. This can:
-Cause direct pressure → electrical conduction abnormalities or reentry circuits.
-Irritate nearby structures like pulmonary veins (triggers for AF).
Stimulate the vagus nerve (increased vagal tone potentially triggering arrhythmias).
-In some cases, related inflammation from GERD (often co-occurs with HH) may play a role via cytokines or neural effects.

28/02/2026

A mixed hiatal hernia, also known as Type III hiatal hernia (or mixed paraesophageal hernia), is a combination of the two main forms of hiatal hernia: sliding (Type I) and paraesophageal (Type II).
In this type:
-The gastroesophageal junction (GEJ) — where the esophagus meets the stomach — slides upward through the diaphragmatic hiatus (similar to a sliding hernia).
-At the same time, a portion of the stomach (typically the fundus or upper part) herniates or "rolls" alongside the esophagus into the chest cavity (paraesophageal component).

Risks and Complications
Because of the mixed nature and larger hiatal defect, Type III carries higher risks than pure sliding hernias, including:
-Gastric volvulus (twisting of the stomach).
-Incarceration or strangulation (compromised blood supply to herniated stomach).
-Obstruction, bleeding, or respiratory compromise.

The treatment consist in:
-Reduction of herniated stomach.
-Hiatal closure (often with mesh reinforcement for larger defects).
-Anti-reflux procedure (e.g., Nissen or partial fundoplication) to prevent post-repair GERD.

22/02/2026

Here is hiatal recurrence few years after the placement of a slowly resorbable mesh. In this case this late recurrences (>12 months post-op) occurred in left-lateral hiatus, in the least reinforced area in traditional posterior-focused repairs where the mesh was not previously placed.
If native tissue healing is incomplete or compromised, recurrence can develop after mesh resorption.
In case of U-shaped posterior mesh configuration leaves the anterior and left-lateral hiatus vulnerable to stretching.
This is attributed to progressive stretching from ongoing physiological stresses rather than acute technical failure.
If native tissue ingrowth is suboptimal (e.g., due to tension or poor healing), recurrence can emerge as support diminishes—though studies show no direct link to resorption timing causing failure; instead, it's more about overall repair durability.

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21/02/2026

-GERD/reflux remains the leading reason for revisional surgery after Sleeve.
-Sleeve Gastrectomy can worsen or cause new-onset severe reflux due to increased intragastric pressure and loss of the angle of His.
- Also weight regain or inadequate weight loss, where the restrictive effect alone isn't sufficient long-term can be indications for conversion

-Conversion to RYGB is often preferred over alternatives (e.g., re-sleeve, duodenal switch, or one-anastomosis bypass) for GERD due to superior reflux control.
-Hiatal closure, if hiatal hernia present, is mandatory

-This Re-do surgery is marked by multiple technical challenges:
The surgical field presents distorted landmarks
The normal gastroesophageal junction anatomy is often displaced
The gastric sleeve creates a more rigid, tubular structure rather than a pliable stomach
Previous staple lines create fibrotic tissue planes

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13/02/2026

13/02/2026

Sliding hiatal hernias occur when the gastroesophageal junction (GEJ) and the upper part of the stomach slide upward through the diaphragmatic hiatus. It is often directly linked to reflux.

For surgical candidates, comprehensive workup (endoscopy + radiological study + manometry + pH measurement ) is recommended to assess motility, reflux severity, and hernia type/size.

The solution : cruroplasty (suturing the crura) + fundoplication (e.g., Nissen or Toupet) to address GERD with use of mesh for specific cases.

06/02/2026

Silastic Ring Vertical Gastroplasty (SRVG) 18 years ago and silastic removal 2 years ago.

Studies report stenosis it in around 8-9% of patients in long-term follow-up (e.g., 8.92% in one 10-year study).

Actually important dysphagia.
Indication for conversion to RYGB.

21/01/2026

In patients who have undergone gastric sleeve surgery, a potential complication is intrathoracic migration (also called sleeve migration or pouch migration) of the remaining gastric sleeve into the hiatal hernia defect.

This can happen due to factors like incomplete hiatal hernia repair during the original surgery, changes in anatomy after weight loss, or increased intra-gastric pressure.

An abdominal reduction of the stomac, hiatal closure and conversion to Roux-en-Y gastric bypass is the first option.

11/01/2026

Hiatal closure with non-absorbable barbed V-Loc (running suture) to approximate the crura under reduced tension is described as safe, efficient, and effective in several series, with advantages including:
- Better tissue apposition and even tension distribution: potentially better tissue approximation and less tearing through fragile crural muscle.
- Permanent strength → may help resist long-term recurrence from diaphragm motion and intra-abdominal pressure.
- Knotless design avoids bulky knots that could cause irritation or dysphagia, but also adhesions.

Here is a video of a Nissen surgery that I performed using non-absorbable V Loc:

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10/01/2026

Retrore**al hamartoma, also known as retrore**al cystic hamartoma or tailgut cyst, is a rare congenital cystic lesion that develops in the presacral (retrore**al) space — the potential space located behind the re**um and in front of the sacrum and coccyx.
It arises from embryonic remnants of the postanal primitive hindgut (tailgut) that fail to regress completely during fetal development.

-Extremely rare — only a few hundred cases reported in medical literature.
-Strong female predominance (typically 3:1 to 5:1 ratio), most commonly diagnosed in middle-aged women (30–60 years), though it can occur at any age, including rarely in children or men.
-Usually benign, but carries a small but important risk of malignant transformation.

Symptoms:
-Chronic constipation or change in stool caliber
-Re**al fullness or pressure
-Lower abdominal, pelvic, or perineal pain
-Lower back pain
-Urinary symptoms (e.g., frequency)
-Rarely: re**al bleeding, infection (mimicking abscess or fistula), or neurological issues

Complete surgical excision is the standard of care — even in asymptomatic cases — to prevent complications like infection, recurrence, fistulization, or malignant degeneration.
Approaches depend on size/location:
Transsacral, transanal/transre**al, abdominal (open/laparoscopic), or combined.

24/12/2025