Background

We present a case of a 56 year old male who underwent a laparoscopic Roux-en-Y gastric bypass in 2011 for metabolic syndrome and multiple obesity-associated diseases. The patinet developed severe GERD symtpoms for several years which were mostly related to an incompetent lower esophageal sphincter and a large hiatal hernia that eventually required an anti-reflux procedure consisting of a robotic hiatal hernia repair and gastric remnant Toupet fundoplication. This was performed in the context of cirrhosis and the possibility of higher risk of iatrognic complications if a distalization of the Roux limb was chosen. After a multidisciplinary team evaluation, the patient underwent the procedures described in addition to repair of an umbilical hernia without mesh. The fundoplication performed with the gastric remnant and the hiatal hernia repair without mesh were successful and eventually led to resolution of the patient's GERD symptoms and improvement in his quality of life. The robotic platform offered several ergonomic advantages that facilitated fine dissection in the setting of large varices and cirrhosis while minimizing tissue trauma and blood loss. Moreover, it is possible and feasible to create a partial fundoplication valve with the gastric remnant in the context of cirrhosis after a Roux-en-Y gastric bypass.