What is the recommended surgical approach for treating symptomatic sliding hiatal hernias?

Surgical Management of Symptomatic Sliding Hiatal Hernias

For symptomatic sliding hiatal hernias, a minimally invasive laparoscopic approach with primary repair using non-absorbable sutures and fundoplication is strongly recommended as the standard surgical treatment. 1

Diagnostic Criteria

Before considering surgical intervention, confirm:

• Symptomatic presentation (GERD symptoms, dysphagia, chest pain)
• Objective evidence of pathologic GERD (erosive esophagitis, Barrett's esophagus, or abnormal pH study) 2
• Inadequate response to medical therapy, including PPI trials 2

Surgical Approach Selection

First-Line Approach

• Laparoscopic repair is the preferred approach for stable patients with sliding hiatal hernias 1
  • Lower morbidity rate (5-6%) compared to open approach (17-18%) 1
  • Shorter hospitalization and faster return to normal activities 3
  • Overall in-hospital mortality rate of only 0.14% 1

Alternative Approaches

• Open laparotomy should be reserved for:

  • Unstable patients 1
  • Failed laparoscopic attempts
  • Complex anatomical situations

• Robotic-assisted repair may be considered in:

  • Clinically stable patients
  • Facilities with experienced surgical and nursing teams 1

Technical Aspects of Repair

Essential Components

1. Reduction of herniated contents into the abdominal cavity
2. Excision of the hernia sac (controversial but may reduce recurrence) 1
3. Primary repair of diaphragmatic defect using non-absorbable sutures 1
   • For defects >8 cm or >20 cm², mesh reinforcement is recommended 1
4. Fundoplication to anchor the stomach in the abdomen and control reflux 3

Fundoplication Options

• Nissen fundoplication (360° wrap): Most commonly performed 1
• Toupet fundoplication (270° posterior wrap): May have lower recurrence rates 1
• Selection should be based on esophageal motility 2

Mesh Considerations

• Mesh should overlap defect edge by 1.5-2.5 cm 1
• Biosynthetic or biologic meshes preferred in clean-contaminated fields 1
• Avoid tackers near the pericardium to prevent cardiac complications 1

Special Considerations

• Elderly or high-risk patients: Consider PEG or combined PEG/laparoscopy approach for symptom relief with lower morbidity 1
• Patients with gastroesophageal reflux history: Include fundoplication as part of repair 1
• Patients with oral intake difficulties: Consider gastrostomy or PEG 1

Postoperative Complications

Common complications include:

• Pulmonary complications (atelectasis)
• Surgical site infection
• Bleeding
• Respiratory failure
• Ileus
• Chronic pain
• Hernia recurrence (reported in 3-5% of cases) 1, 3

Follow-up Recommendations

• Barium swallow study to evaluate repair integrity
• Continue PPI therapy in patients with Barrett's esophagus 2
• Regular surveillance for patients with Barrett's esophagus (every 3-5 years for non-dysplastic cases) 2

Pitfalls to Avoid

• Inadequate mobilization: Ensure complete mobilization of the esophagus to prevent tension
• Missed diagnosis of short esophagus: May require additional procedures like Collis gastroplasty 1
• Inappropriate patient selection: Confirm objective evidence of pathologic GERD before surgery 2
• Inadequate mesh fixation: Can lead to mesh migration and recurrence 1

The laparoscopic approach with primary repair and fundoplication offers excellent symptom control while minimizing morbidity, making it the preferred surgical option for symptomatic sliding hiatal hernias.