Are there minimally invasive options for hiatal hernia repair?

Minimally Invasive Options for Hiatal Hernia Repair

Laparoscopic surgery is the preferred minimally invasive approach for hiatal hernia repair in stable patients, offering excellent safety with a reported in-hospital mortality rate of only 0.14%. 1

Types of Minimally Invasive Approaches

• Laparoscopic repair is the gold standard for hiatal hernia treatment, providing lower morbidity (5-6%) compared to open surgical approaches (17-18%) 2
• Robotic surgery is an emerging option, though currently has limited supporting data 1
• For specific cases with spontaneously reduced strangulated hernias, hernioscopy (a mixed laparoscopic-open technique) can be used to evaluate bowel viability and prevent unnecessary laparotomy 3

Indications for Minimally Invasive Repair

• Symptomatic hiatal hernias that fail medical management 2
• Complicated hiatal hernias (incarceration, volvulus) in stable patients 1, 2
• Large paraesophageal hernias (types III and IV) can be safely repaired laparoscopically 4
• Presence of gastroesophageal reflux disease (GERD) requiring long-term treatment 2

Surgical Technique

• Primary repair with non-absorbable sutures should always be attempted first 1, 2
• For defects larger than 8 cm or area greater than 20 cm², mesh reinforcement is recommended 1, 2
  • Mesh should overlap the defect edge by 1.5-2.5 cm 1
  • Mesh can be fixed using tackers or transfascial sutures (avoid tackers near pericardium) 1
• Anti-reflux procedure should be performed concurrently 1, 2
  • Nissen fundoplication is most common 2, 5
  • Toupet fundoplication is an alternative with potentially lower recurrence rates in some studies 2
• For patients with shortened esophagus, Collis gastroplasty may be combined with fundoplication (Collis-Nissen procedure) 5

Outcomes and Benefits

• Laparoscopic repair has demonstrated good to excellent postoperative outcomes comparable to the best open surgery series 5
• Low recurrence rates (2.7% requiring revision surgery) have been reported with proper technique 5
• Patients report marked improvement in quality of life (76% reporting evidently positive outcomes) 4
• Mean hospital stay is significantly shorter than open procedures (approximately 6.2 days) 6
• Conversion to open surgery is rare, with rates around 11% 6

Potential Complications

• Postoperative pulmonary complications (atelectasis) 1, 2
• Surgical site infection, bleeding, respiratory failure 1, 2
• Gastroesophageal reflux (up to 62% incidence if fundoplication not performed) 1
• Chronic pain and hernia recurrence 1, 2
• Dysphagia (may occur in a small percentage of patients) 6

Special Considerations

• For unstable patients with complicated hiatal hernias, open surgical approach (laparotomy) is still recommended 1, 2
• For high-risk elderly patients, gastropexy or percutaneous endoscopic gastrostomy (PEG) may be considered as less invasive alternatives 1
• Thoracic surgeons experienced in minimally invasive esophageal surgery can also safely perform these procedures 6

Follow-up and Monitoring

• Regular follow-up with imaging studies to detect potential recurrence 6
• Monitoring for persistent symptoms such as reflux or dysphagia 6
• Long-term proton pump inhibitor therapy may be needed in some patients despite successful repair 2