What are the indications for hiatal hernia repair?

Indications for Hiatal Hernia Repair

Hiatal hernia repair is indicated for patients with proven GERD who have failed medical management, patients with symptomatic paraesophageal hernias, and those with complicated hiatal hernias showing signs of strangulation, incarceration, or perforation requiring immediate surgical intervention. 1

Primary Indications for Hiatal Hernia Repair

1. Symptomatic GERD with Hiatal Hernia

• Persistent symptoms despite optimized PPI therapy
• Objective evidence of pathologic GERD on testing
• Presence of a hiatal hernia contributing to reflux symptoms
• Regurgitation-predominant GERD (responds particularly well to surgical repair) 1

2. Paraesophageal Hernias (PEHs)

• All symptomatic paraesophageal hernias (Types II, III, and IV) 2
• Symptoms may include:
  • Epigastric or chest pain
  • Dysphagia
  • Dyspnea
  • Early satiety
  • Nausea and vomiting
  • Hematemesis 2

3. Complicated Hiatal Hernias

• Immediate surgical intervention required for:
  • Strangulation
  • Incarceration
  • Gastric volvulus
  • Perforation 1, 2
• These complications can rapidly progress to peritonitis, sepsis, and death if not addressed promptly 2

Pre-operative Evaluation Requirements

Before proceeding with hiatal hernia repair, the following diagnostic workup is essential:

1. Confirmatory evidence of pathologic GERD 1

   • Upper GI endoscopy to assess for erosive disease or Barrett's esophagus
   • 24-hour pH monitoring to confirm abnormal acid exposure

2. Assessment of esophageal peristaltic function 1

   • High-resolution manometry to exclude achalasia and evaluate esophageal motility
   • Particularly important for determining type of fundoplication (partial vs. complete)

3. Anatomic evaluation 2

   • Double-contrast upper GI series (barium esophagram) - essential for surgical planning
   • CT scan for complicated cases or when diaphragmatic defects are suspected

Surgical Approach Selection

For Uncomplicated Hiatal Hernias with GERD

• Laparoscopic fundoplication with hiatal hernia repair is the standard approach 1
• Type of fundoplication should be tailored:
  • Complete (Nissen) fundoplication for normal esophageal motility
  • Partial fundoplication for patients with esophageal hypomotility or impaired peristaltic reserve 1

For Paraesophageal Hernias

• Laparoscopic approach with crural repair is preferred in stable patients 1
• Magnetic sphincter augmentation combined with crural repair is an alternative option 1

For Complicated Hiatal Hernias

• Abdominal approach (laparotomy) is recommended for unstable patients or those with signs of strangulation/perforation 1
• Thoracic approach may be necessary in chronic herniation with viscero-pleural adhesions 1

Special Considerations

Obesity

• In obese patients with proven GERD, Roux-en-Y gastric bypass is an effective primary anti-reflux intervention 1
• Sleeve gastrectomy should be avoided as it may worsen GERD 1
• Concurrent hiatal hernia repair during bariatric surgery is recommended when hiatal hernia is present 3

Minimally Invasive Options

• Transoral incisionless fundoplication (TIF) may be considered for carefully selected patients with small hiatal hernias 1, 4
• Recent evidence suggests TIF with hiatal hernia repair has lower early adverse events compared to Nissen fundoplication, but long-term outcomes remain under investigation 4, 5

Common Pitfalls and Caveats

1. Asymptomatic hiatal hernias generally do not require surgical intervention unless they are large paraesophageal hernias with risk of complications 6

2. Inadequate preoperative evaluation can lead to poor outcomes:

   • Failure to diagnose achalasia can result in worsened dysphagia after fundoplication
   • Unrecognized esophageal hypomotility may lead to dysphagia if complete fundoplication is performed 1

3. Technical considerations:

   • Inadequate mobilization of the esophagus can lead to recurrence
   • At least 3 cm of intra-abdominal esophageal length should be achieved 6
   • Crural closure with mesh reinforcement may be necessary for large defects 6

4. Delayed diagnosis of complicated hiatal hernias can lead to increased mortality rates, with studies showing 14.6% of cases having delayed diagnosis until clinical deterioration 2

By following these evidence-based indications and approaches to hiatal hernia repair, clinicians can optimize patient outcomes while minimizing morbidity and mortality associated with both the condition and its surgical management.