When is surgery recommended for a patient with a hiatal hernia and severe gastroesophageal reflux disease (GERD) symptoms?

When to Perform Surgery for Hiatal Hernia

Surgery for hiatal hernia is indicated when patients have objectively confirmed GERD that fails optimal medical therapy (including twice-daily PPI), particularly in those with troublesome regurgitation, PPI intolerance, or large hiatal hernias (>2 cm) causing mechanical symptoms. 1, 2

Mandatory Pre-Surgical Requirements

Before any surgical intervention, the following must be completed:

• Objective GERD confirmation through ambulatory 24-hour pH monitoring (preferably off PPI) or pH-impedance monitoring is essential 1, 2, 3
• High-resolution manometry to exclude achalasia and assess esophageal peristaltic function, as impaired motility influences the type of fundoplication 1, 2, 3
• Upper endoscopy to evaluate for erosive esophagitis, Barrett's esophagus, strictures, and hiatal hernia size 1
• Barium swallow is necessary before surgery to identify hiatal hernia size, strictures, or short esophagus 1

Specific Surgical Indications

Strong Indications:

• PPI-refractory GERD with persistent troublesome regurgitation despite optimized medical therapy 1
• PPI intolerance in patients with documented GERD 1
• Large hiatal hernia (>2 cm) requiring anatomic repair, with laparoscopic fundoplication and hiatal hernia repair being the appropriate surgical option 2, 4
• Severe erosive esophagitis poorly controlled on medical therapy 1

Relative Indications:

• Extraesophageal GERD syndromes (reflux cough, reflux asthma) where reflux causality has been established, though this should be recommended with appropriate restraint 1
• Young patients with confirmed GERD requiring lifelong PPI therapy who prefer definitive treatment 1

Contraindications to Surgery

Patients who should NOT undergo surgery:

• Those well-controlled on medical therapy have nothing to gain from surgery and incur added risk 1
• Patients with functional heartburn (normal pH studies) have poor surgical outcomes 2, 3
• Presence of achalasia or severe esophageal dysmotility without appropriate surgical modification 1, 2

Surgical Approach Selection

For Normal Esophageal Motility:

• Laparoscopic Nissen fundoplication (360°) is the gold standard with success rates up to 80% at 20-year follow-up 2, 5, 6

For Impaired Esophageal Motility:

• Partial fundoplication (Toupet 270°) is preferred when esophageal hypomotility or impaired peristaltic reserve is present to reduce postoperative dysphagia risk 1, 2, 5

For Large Hiatal Hernias:

• Mesh reinforcement of the diaphragmatic hiatus should be considered for hernias >5 cm to reduce recurrence rates, with a 0% recurrence rate and very low mesh-related complications 4

Alternative Options:

• Magnetic sphincter augmentation combined with crural repair is an option for confirmed GERD with hiatal hernia 1
• Transoral incisionless fundoplication (TIF) is effective only in carefully selected patients with confirmed GERD and no hiatal hernia or minor crural defect (<2 cm) 1, 2, 7
• Roux-en-Y gastric bypass is the primary anti-reflux intervention for obese patients with GERD 1, 7

Critical Pitfalls to Avoid

• Never proceed with endoscopic fundoplication if hiatal hernia is >2 cm, as this is associated with high failure rates 2, 3
• Do not perform any anti-reflux procedure without objective GERD confirmation, as patients with functional heartburn have poor outcomes 2, 3
• Avoid surgery as cancer prevention in Barrett's esophagus, as no protective effect has been demonstrated and surgical mortality exceeds cancer risk 1
• Be aware that 30% of patients resume medical therapy by 5 years after surgery, and surgical revision is common 1
• Postoperative dysphagia requiring dilation occurs in approximately 6% of patients, and new symptoms (flatulence, inability to belch, gas bloat) are common 1

Quality of Life Considerations

Surgery demonstrates statistically significant improvements in health-related quality of life at 3 months and 1 year compared to medical therapy 1. However, the LOTUS trial showed that at 5 years, remission rates were higher in the medication group (92%) than the surgical group (85%), though this difference became non-significant after accounting for dropouts 1. The benefits must be weighed against potential postoperative symptoms including dysphagia, gas bloat syndrome, and inability to belch 1.