How is a large hiatal hernia that is mostly intrathoracic repaired, and why is a fundoplication performed with the repair?

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Last updated: September 26, 2026 • View editorial policy

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Repair of Large Intrathoracic Hiatal Hernia

For a large hiatal hernia that is mostly intrathoracic, perform laparoscopic reduction of herniated contents, excision of the hernia sac, primary repair of the hiatal defect with non-absorbable sutures (using mesh reinforcement for defects >8 cm or >20 cm²), and add a fundoplication to prevent postoperative gastroesophageal reflux. 1

Surgical Approach

Patient Stability Determines Access

  • Stable patients: Minimally invasive (laparoscopic) approach is preferred, with lower morbidity (5-6%) compared to open surgery (17-18%) 1
  • Unstable patients: Laparotomy is indicated 1
  • Right-sided hernias: May require combined or thoracic approach due to liver interference 1

Technical Steps for Repair

1. Reduction and Sac Management

  • Reduce all herniated contents (stomach, colon, omentum, small bowel) back into abdomen
  • Perform adequate mediastinal dissection to achieve >2 cm of intra-abdominal esophagus
  • Hernia sac excision is controversial but may reduce recurrence risk, especially when colon or stomach is contained within the sac 1

2. Hiatal Defect Repair

  • Primary closure: Attempt first with non-absorbable sutures when tension-free closure is possible 1
  • Mesh reinforcement: Required for defects >8 cm or area >20 cm² when primary closure creates excessive tension 1
    • Mesh should overlap defect edges by 1.5-2.5 cm 1
    • In clean-contaminated/contaminated fields, use biologic or biosynthetic meshes 1
    • Avoid tackers near pericardium due to cardiac injury risk 1

3. Fundoplication

  • Nissen (360°) fundoplication: Most commonly performed technique 1
  • Toupet (posterior 180-270°) fundoplication: May have lower recurrence rates than Nissen 1
  • Both techniques provide similar gastroesophageal barrier restoration 1

Why Fundoplication is Essential

The incidence of gastroesophageal reflux after large hiatal hernia repair reaches up to 62% without fundoplication 1. Key evidence supporting fundoplication:

  • Prevents postoperative reflux: A 2015 randomized controlled trial demonstrated that repair without fundoplication resulted in significantly higher DeMeester scores (40.9 vs 9.6, p=0.048) and esophagitis rates (53% vs 17%, p=0.026) at follow-up 2
  • No significant increase in side effects: Dysphagia and gas-bloat syndrome rates were similar between groups with and without fundoplication 2
  • Specific indications include: History of GERD, large defect repair, paraesophageal hernia, or congenital hernia 1

Additional Procedures When Needed

  • Gastropexy: Perform after detorsion if gastric volvulus is present 1
  • Collis gastroplasty: Reserved for true short esophagus that persists despite adequate mediastinal dissection 1

Critical Technical Considerations

Avoiding Common Pitfalls

  • Recurrence prevention: Use non-absorbable sutures for primary repair; absorbable sutures increase recurrence risk 1
  • Adequate overlap: Ensure mesh extends 1.5-2.5 cm beyond defect edges 1
  • Tension assessment: If distance between diaphragm edge and chest wall exceeds 3-4 cm, do not attempt primary closure—use mesh 1
  • Esophageal length: Achieve minimum 2 cm intra-abdominal esophagus before fundoplication 3

Expected Outcomes

  • Mortality: 0.14% for minimally invasive approach 1
  • Complications: Range 11-62.9%, including pulmonary complications (most common), bleeding, respiratory failure, and hernia recurrence 1
  • Recurrence factors: Improper mesh fixation, minimal overlap, increased intra-abdominal pressure, absorbable sutures, and intra-abdominal sepsis 1

The combination of anatomic repair with fundoplication addresses both the mechanical defect and the high risk of postoperative reflux, providing superior long-term outcomes compared to repair alone.

References

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.