What is the treatment for hiatal hernia via surgical intervention?

From the Guidelines

Hiatal hernia surgery is recommended for patients with severe symptoms that don't respond to medication, those with complications like strangulation or severe GERD, or for large hernias that pose significant risks, with laparoscopic Nissen fundoplication being the most common procedure, as supported by the most recent study 1.

Key Considerations

• The decision to perform hiatal hernia surgery should be based on the severity of symptoms, the presence of complications, and the size of the hernia, as well as the patient's overall health and medical history.
• Laparoscopic Nissen fundoplication is a minimally invasive procedure that involves wrapping the upper part of the stomach around the lower esophagus to strengthen the sphincter and prevent reflux, with a recovery time of 2-6 weeks and a hospital stay of 1-3 days post-surgery 1.
• Before surgery, patients may need to stop certain medications like blood thinners and NSAIDs for 7-10 days, and after surgery, a liquid diet is necessary for 1-2 weeks, gradually advancing to soft foods, with pain management typically including acetaminophen and possibly prescription pain medications for the first week.

Potential Complications

• Potential complications of hiatal hernia surgery include difficulty swallowing, gas bloating, recurrence of the hernia, and infection, as reported in the literature 1.
• The incidence of gastroesophageal reflux after repair of congenital diaphragmatic hernia is high, reaching up to 62%, and fundoplication should be performed during congenital hernia repair to manage the associated gastroesophageal reflux 1.

Surgical Approach

• Minimally invasive abdominal approach can be performed with an excellent safety profile and a reported overall in-hospital mortality rate of 0.14%, with similar outcomes in terms of perioperative morbidity and mortality in both laparotomy and minimally invasive approach 1.
• The choice of surgical procedure, including Nissen fundoplication, Toupet fundoplication, or other techniques, should be tailored to the individual patient's needs and medical history, with factors affecting the surgical procedure selection including the history of gastroesophageal reflux, the need to repair a large defect, a paraesophageal hernia, or a congenital hernia 1.

From the Research

Hiatal Hernia Surgery Overview

• Hiatal hernia surgery can be performed using various techniques, including laparoscopic reduction, crural repair, and fundoplication 2.
• The choice of surgical approach depends on the size of the hernia, the presence of gastroesophageal reflux disease (GERD), and the patient's overall health.

Surgical Techniques

• Laparoscopic hiatal hernia repair with concomitant transoral incisionless fundoplication is a newer procedure that has shown promising results in treating GERD and hiatal hernias 3.
• The use of mesh reinforcement in laparoscopic hiatal hernia repair has been shown to reduce the risk of recurrence 4.
• Cruroplasty alone can be an effective treatment for recurrent hiatal hernia repair in patients with an intact fundoplication or magnetic sphincter augmentation 5.

Outcomes and Efficacy

• Studies have shown that laparoscopic hiatal hernia repair followed by transoral incisionless fundoplication can provide significant symptom control for heartburn and regurgitation with minimal adverse effects 6.
• The efficacy of hiatal hernia surgery can be measured using various questionnaires, including the GERD-HRQL, RSI, and GERSS scores 6.
• The use of proton pump inhibitors can be reduced or eliminated in many patients after hiatal hernia surgery 3, 6.

Patient Selection and Preoperative Evaluation

• Patients with large hiatal hernias or paraesophageal herniation may require a more extensive surgical approach, including the use of mesh reinforcement 4.
• Preoperative evaluation should include endoscopy, manometry, and pH probe testing to assess the severity of GERD and the presence of any underlying motility disorders 4.