What is the best management approach for a middle-aged patient with hiatal hernia pain and a history of vagotomy (vagotomies are surgical procedures that involve cutting the vagus nerve), who may have underlying conditions such as peptic ulcer disease?

Management of Hiatal Hernia Pain in Patients with Prior Vagotomy

For a middle-aged patient with hiatal hernia pain and a history of vagotomy, surgical repair is the recommended treatment approach, but vagotomy should NOT be repeated or added if not already performed, as it significantly increases long-term disabling symptoms without providing additional benefit against reflux recurrence. 1

Key Principle: Vagotomy Complications in Hiatal Hernia Surgery

The critical issue here is understanding that vagotomy adds substantial morbidity to hiatal hernia repair:

• Long-term disabling postoperative symptoms occur in 26% of patients when vagotomy is included versus only 1% without vagotomy 1
• Diarrhea occurs twice as frequently with vagotomy 1
• Nausea and vomiting occur ten times more frequently with vagotomy 1
• Dumping syndrome is present only in vagotomized patients 1
• Vagotomy provides no additional protection against recurrent reflux symptoms or radiographic evidence of recurrent hiatal hernia 1

Surgical Management Algorithm

For Symptomatic Hiatal Hernia with Prior Vagotomy:

1. Preoperative Evaluation:

• Upper endoscopy to assess anatomy and rule out other pathology 2
• Esophagogram (UGI series) to define hernia type and size 2
• Esophageal manometry to assess motility 2
• 24-hour pH-impedance monitoring if symptoms persist despite medical therapy 3

2. Surgical Approach Selection:

• Laparoscopic repair is preferred for stable patients with lower morbidity (5-6%) compared to open approach (17-18%) 4, 3
• Open laparotomy is reserved for unstable patients or those with complications 4, 5
• Thoracic approach may be necessary for chronic hernias with viscero-pleural adhesions or right-sided hernias complicated by liver position 4, 5

3. Surgical Technique Components:

The repair must include these essential elements:

• Reduction of hernia contents 2
• Removal of hernia sac (though controversial, may reduce recurrence) 4
• Closure of hiatal defect with interrupted non-absorbable 2-0 or 1-0 sutures in two layers 4
• Mesh reinforcement for defects >8 cm or area >20 cm², with mesh overlapping defect edges by 1.5-2.5 cm 3, 5
• Fundoplication should be routinely performed 6

4. Fundoplication Choice:

• Nissen fundoplication is the most common technique 3
• Toupet fundoplication is an alternative with potentially lower recurrence rates according to some studies 4, 3

Critical Caveat: Do NOT Add Vagotomy

Vagotomy is contraindicated in hiatal hernia repair except in the presence of active peptic ulcer disease 1. Since your patient already has a history of vagotomy (presumably for prior peptic ulcer disease), the focus should be on:

• Managing the hiatal hernia itself without additional vagal nerve manipulation
• Recognizing that the prior vagotomy may contribute to current symptoms (gastroparesis, dumping, diarrhea)
• Considering prokinetic agents if gastroparesis coexists 3

Medical Optimization Before Surgery

If surgery is delayed or patient prefers initial conservative management:

• Lifestyle optimization (weight loss, head of bed elevation, dietary modifications) 3
• Proton pump inhibitor optimization 3
• Adjunctive therapy with alginates, H2-antagonists, or baclofen 3
• Prokinetics if gastroparesis is present (which may be related to prior vagotomy) 3

Expected Outcomes

• Symptom resolution rates: 65% for dysphagia, 68% for heartburn, 95% for chest pain, 79% for regurgitation 7
• Recurrence risk factors include: inadequate initial repair, very broad hiatal opening, severe esophagitis, and use of absorbable sutures 4, 8
• Para-operative complications occur in approximately 37% of redo cases 7

Special Consideration for Redo Surgery

If this patient has already had prior hiatal hernia repair (in addition to vagotomy), the approach becomes more complex:

• Thorough preoperative evaluation is essential to identify mechanism of failure 7
• Screen for psychosomatic factors, as these patients have poor outcomes with reoperation 8
• Laparoscopic approach is still appropriate in selected patients 7
• Consider thoracic or thoracoabdominal approach if extensive adhesions are anticipated 8