From the Guidelines
A 2-3cm hiatal hernia alone is generally not an indication for laparoscopic diaphragmatic hernia repair with Nissen fundoplication and mesh. According to the most recent evidence, surgery is typically reserved for patients with persistent, severe symptoms that significantly impact quality of life despite adequate medical therapy, or for complications such as stricture, ulceration, or respiratory issues 1. Small hiatal hernias (less than 5cm) are common findings and often asymptomatic or manageable with lifestyle modifications and medications. The use of mesh in diaphragmatic hernia repair is recommended for larger defects that cannot be closed primarily, and the choice of mesh material depends on the surgeon's experience and preference 1.
Key Considerations
- Initial treatment should focus on proton pump inhibitors (such as omeprazole 20-40mg daily or esomeprazole 20-40mg daily), weight loss if applicable, avoiding meals within 3 hours of bedtime, elevating the head of the bed, and avoiding trigger foods.
- Surgical intervention carries risks including dysphagia, gas bloat syndrome, and recurrence, which must be weighed against potential benefits.
- The decision for surgery should be individualized based on symptom severity, response to medical therapy, and patient preference after thorough discussion with a gastroenterologist and surgeon, rather than hernia size alone.
- Factors affecting the surgical procedure selection include the history of gastroesophageal reflux, the need to repair a large defect, a paraesophageal hernia, or a congenital hernia 1.
Mesh Repair
- A mesh should be used for larger defects, and biological meshes have a lower rate of hernia recurrence, higher resistance to infections, and lower risk of displacement compared with synthetic meshes 1.
- The reconstruction is typically performed with synthetic meshes, which are well tolerated and can be bio-prosthetic materials or entirely artificial mesh, either absorbable or non-absorbable.
From the Research
Indications for Laparoscopic Diaphragmatic Hernia Repair
- A 2-3cm hiatal hernia may be an indication for laparoscopic diaphragmatic hernia repair with Nissen fundoplication and mesh, as studies have shown that laparoscopic repair is a feasible and effective treatment option for hiatal hernias 2.
- The use of mesh in hiatal hernia repair is a topic of debate, with some studies suggesting that it may be beneficial in reducing recurrence rates 3, while others have found the evidence to be equivocal 4.
Surgical Techniques
- Laparoscopic Nissen fundoplication is a commonly used technique for repairing hiatal hernias, and is often considered the standard for treating gastroesophageal reflux disease-related hiatal hernias 5.
- Other techniques, such as Toupet fundoplication, may be used in patients with specific conditions, such as impaired esophageal motility 3.
- The use of mesh reinforcement of the diaphragmatic hiatus may be necessary to complete a repair without tension, especially in larger hernias 3.
Patient Selection
- Patient selection is crucial in determining the best course of treatment for hiatal hernias, and factors such as esophageal motility and the presence of gastroesophageal reflux disease should be taken into account 3, 4.
- Asymptomatic patients with hiatal hernias may be offered surgical repair, but the decision should be made on a case-by-case basis, taking into account the patient's individual circumstances and the potential risks and benefits of surgery 4.