Does a 6 cm hiatal hernia require surgical intervention?

Management of a 6 cm Hiatal Hernia

Surgery is not routinely recommended for an uncomplicated 6 cm hiatal hernia unless it is symptomatic or has developed complications. 1

Decision Algorithm for Hiatal Hernia Management

Assessment of Need for Surgical Intervention

• Asymptomatic hiatal hernias: Watchful waiting is appropriate regardless of size 2
• Symptomatic hiatal hernias: Require operative repair with an anti-reflux procedure 2
• Complicated hiatal hernias: Surgery is strongly recommended (Strong recommendation based on moderate-quality evidence, 2C) 1

Symptoms and Complications Warranting Surgery

• Obstructive symptoms: Difficulty swallowing, early satiety, chest pain
• Severe GERD symptoms: Not controlled with medical therapy
• Complications:
  • Incarceration
  • Volvulus
  • Strangulation
  • Bleeding
  • Severe respiratory symptoms

Surgical Approach When Indicated

• For stable patients: Minimally invasive approach (laparoscopic) is suggested (Weak recommendation based on very low-quality evidence, 2D) 1

  • Benefits: Shorter hospital stays, fewer wound infections, shorter recovery time
  • Overall in-hospital mortality rate of only 0.14% 1

• For unstable patients: Open laparotomy approach is suggested (Weak recommendation based on low-quality evidence, 2C) 1

Key Operative Steps When Surgery is Performed

1. Reduction and excision of hernia sac
2. Establishment of 3 cm of intra-abdominal esophageal length
3. Crural closure with non-absorbable sutures 1
4. Mesh reinforcement for defects larger than 8 cm or area >20 cm² 1
   • Mesh should overlap defect edge by 1.5-2.5 cm
   • Avoid tackers near pericardium due to risk of cardiac complications
5. Anti-reflux procedure (typically fundoplication) 2

Special Considerations for Elderly or High-Risk Patients

• For elderly patients with comorbidities who cannot tolerate definitive repair:
  • Gastropexy (fixation of stomach to abdominal wall) can be considered
  • PEG or combined PEG/laparoscopy approach may be successful in relieving symptoms
  • These approaches have very low morbidity and are well tolerated 1

Prognosis and Outcomes

• Natural history: Asymptomatic hiatal and paraesophageal hernias become symptomatic at a rate of only 1% per year 2
• Recurrence rates after repair can be high (up to 60% at 12 years), but most recurrences are asymptomatic 3
• Functional outcomes and quality of life improvements are more important measures of success than anatomic recurrence 3

Important Caveats

• Size alone (6 cm) is not an absolute indication for surgery
• The presence of symptoms and complications should guide the decision for surgical intervention
• Delaying treatment of complicated hiatal hernias can lead to increased morbidity and mortality
• Prophylactic repair to prevent acute complications should be considered individually, especially in patients younger than 75 in good condition 3