From the Guidelines
The most effective approach for managing hiatal hernia is to prioritize Nissen fundoplication for uncomplicated cases with gastroesophageal reflux disease, reserving mesh repair for larger hernias or recurrent cases where tissue reinforcement is necessary. This approach is supported by recent studies, including a 2023 position paper by Giuffrida et al. 1, which highlights the importance of considering factors such as hernia size, patient symptoms, and risk of recurrence when deciding between mesh repair and Nissen fundoplication.
Key considerations in the management of hiatal hernia include:
- Hernia size: Mesh repair is typically reserved for larger hernias (greater than 5 cm) or recurrent hernias where tissue reinforcement is needed to prevent recurrence.
- Patient symptoms: Nissen fundoplication is generally preferred for uncomplicated hiatal hernias with gastroesophageal reflux disease, as it provides excellent reflux control without the long-term complications associated with mesh.
- Esophageal motility: This factor should be taken into account when deciding between mesh repair and Nissen fundoplication, as it can impact the success of the procedure.
- Risk of recurrence: Mesh repair may be preferred for patients with a high risk of recurrence, as it provides better anatomical support for large hernias.
It's also important to note that Nissen fundoplication and Toupet fundoplication have similar effects on restoration of the mechanical gastroesophageal barrier against gastric reflux, although some studies suggest that Toupet fundoplication may have a lower recurrence rate 1. Additionally, a 2022 clinical practice update by the American Gastroenterological Association recommends laparoscopic fundoplication as an effective surgical option for patients with proven GERD 1.
Post-operative care for both mesh repair and Nissen fundoplication includes a gradual return to normal diet, avoiding heavy lifting for 6-8 weeks, and follow-up endoscopy to assess repair integrity. Patients should be informed about the potential risks and benefits of each approach, including the risks of mesh erosion, infection, and dysphagia associated with mesh repair, and the potential for higher recurrence rates with Nissen fundoplication for very large hernias.
From the Research
Management of Hiatal Hernia: Mesh vs Nissen Fundoplication
- The management of hiatal hernia can be done through various surgical approaches, including Nissen fundoplication and the use of mesh to repair the hernia 2, 3, 4, 5, 6.
- Laparoscopic Nissen fundoplication is a commonly used procedure for the treatment of gastroesophageal reflux disease (GERD) and hiatal hernia, with a low rate of dysphagia and recurrent reflux 2, 3.
- The use of mesh to repair large paraesophageal hernias has been shown to result in a low recurrence rate, with no instances of infection or bowel fistulization related to the use of mesh 2, 4.
- Studies have compared the efficacy of laparoscopic Nissen fundoplication versus Toupet fundoplication for the management of types III and IV hiatal hernias, with similar long-term postoperative symptom control 3.
- The role of fundoplication in the treatment of patients with symptoms of hiatal hernia has been evaluated, with results suggesting that laparoscopic hiatal hernia repair with concomitant Nissen fundoplication is safe and effective in improving reflux-related symptoms and reducing the incidence of complications 5.
- A retrospective study compared hiatal hernia repair with transoral incisionless fundoplication versus Nissen fundoplication for gastroesophageal reflux disease, finding that the transoral incisionless fundoplication approach was associated with lower early and serious adverse events compared to Nissen fundoplication 6.
Key Findings
- Laparoscopic Nissen fundoplication is a effective procedure for the treatment of GERD and hiatal hernia 2, 3.
- The use of mesh to repair large paraesophageal hernias is a safe and effective approach 2, 4.
- Fundoplication plays an important role in the treatment of patients with symptoms of hiatal hernia 5.
- Transoral incisionless fundoplication may be a viable alternative to Nissen fundoplication for the treatment of GERD and hiatal hernia, with lower adverse event rates 6.
Surgical Approaches
- Laparoscopic Nissen fundoplication: a 360-degree wrap of the fundus around the esophagus 2, 3.
- Toupet fundoplication: a 270-degree wrap of the fundus around the esophagus 2, 3.
- Transoral incisionless fundoplication: a minimally invasive approach that uses a transoral incisionless fundoplication device to repair the hernia 6.
- Mesh repair: the use of a mesh to reinforce the diaphragmatic hiatus and prevent recurrence of the hernia 2, 4.