What are the best management options for a middle-aged patient with a history of vagotomy and recurring hiatal hernia experiencing chronic pain?

Management of Chronic Pain in Recurring Hiatal Hernia After Vagotomy

For a patient with recurring hiatal hernia and chronic pain, surgical repair is the definitive treatment, with laparoscopic approach being preferred, incorporating crural closure with non-absorbable sutures, mesh reinforcement for defects >3 cm, and fundoplication tailored to esophageal motility. 1, 2

Surgical Approach for Recurrent Hernia

Laparoscopic repair is the gold standard for recurrent hiatal hernias in stable patients, offering lower morbidity (5-6%) compared to open surgery (17-18%) and excellent safety profile with in-hospital mortality of only 0.14%. 2, 3 However, redo surgery for recurrent hernias is technically challenging and should only be pursued in symptomatic patients whose pain is definitively attributable to the recurrent hernia. 4

Key Technical Components

The surgical repair must address the high recurrence rates (up to 42% with primary repair alone) through several critical steps: 2

• Primary crural closure using interrupted non-absorbable sutures (2-0 or 1-0 monofilament) in two layers is essential, as absorbable sutures contribute to recurrence. 2, 3

• Mesh reinforcement is mandatory for defects >3 cm or when primary repair creates excessive tension, as this significantly reduces recurrence rates. 1, 2 Biosynthetic, biologic, or composite meshes are preferred due to lower recurrence rates, higher infection resistance, and lower displacement risk, with mesh overlapping defect edges by 1.5-2.5 cm. 2

• Complete excision of the hernia sac must be performed to prevent recurrence. 3

Fundoplication Selection Based on Prior Vagotomy

Given the patient's history of vagotomy, esophageal motility is likely compromised, which critically influences fundoplication choice:

• Partial fundoplication (Toupet) is preferred in patients with esophageal hypomotility or impaired peristaltic reserve to reduce postoperative dysphagia risk, which is particularly relevant after vagotomy. 1, 2

• Nissen fundoplication (360° wrap), while the gold standard for durable GERD relief, carries higher risk of postoperative dysphagia and should be avoided in patients with compromised motility. 1, 2

Mandatory Preoperative Assessment

Before proceeding with redo surgery, comprehensive evaluation is required to confirm the hernia is causing symptoms and to plan the appropriate repair:

• High-resolution manometry to assess esophageal peristaltic function and exclude achalasia—this is particularly important given the prior vagotomy. 1, 2

• Complete endoscopic evaluation to document severity of esophagitis and assess for complications. 1, 2

• CT scan is the gold standard for diagnosis with 87% specificity. 2

• Upper GI series to define anatomical relationships and assess for short esophagus, which occurs in most paraesophageal hernias due to chronic reflux. 5

Novel Adjunctive Technique for High-Risk Recurrence

For patients with obesity or prior recurrence, gastrojejunopexy (the "leash maneuver") represents an emerging technique where a jejunal segment near the ligament of Treitz is anchored to the stomach's greater curvature, providing downward traction and reducing recurrence risk. 6 This showed no recurrence at 8-month follow-up in a high-risk obese patient with prior failed repair. 6

Alternative for High-Risk Surgical Candidates

If the patient is elderly or has significant comorbidities making definitive repair too risky, percutaneous endoscopic gastrostomy (PEG) or gastrostomy is suggested as a palliative option to prevent gastric volvulus and reduce pain. 2

Expected Outcomes

Redo surgery for recurrent hiatal hernia achieves:

• 80% excellent results (symptom-free) 5
• 65-95% resolution of specific symptoms (dysphagia 65%, heartburn 68%, chest pain 95%, regurgitation 79%) 7
• Re-recurrence rate of approximately 10% even with optimal technique 7
• Overall patient satisfaction of 6.94/10 7

Critical Pitfalls to Avoid

• Do not use absorbable sutures for crural closure, as this is a major cause of recurrence. 2, 3

• Do not perform Nissen fundoplication in patients with prior vagotomy or documented esophageal dysmotility, as this will cause severe postoperative dysphagia. 1

• Do not proceed without confirming the recurrent hernia is causing the pain, as symptoms may be from other causes in this complex patient. 4

• Do not attempt primary repair alone in recurrent hernias, as the recurrence rate is prohibitively high at 42%. 2