In a 72‑year‑old woman with a symptomatic para‑esophageal hiatal hernia who also has a supra‑umbilical abdominal wall hernia, should a hernia belt be used or is surgical repair indicated?

Management of Supra-Umbilical Hernia in a Patient with Symptomatic Para-Esophageal Hiatal Hernia

Surgical repair of the supra-umbilical hernia with mesh is indicated and should be performed, ideally staged after or concurrent with the para-esophageal hernia repair, as hernia belts are not a definitive treatment and all symptomatic abdominal wall hernias should be repaired to prevent complications. 1

Primary Recommendation for the Abdominal Wall Hernia

Mesh repair is mandatory for the supra-umbilical hernia regardless of size, as mesh significantly reduces recurrence rates (0-4.3% with mesh vs 19% with tissue repair alone). 1, 2 Hernia belts provide only temporary symptomatic relief and do not prevent progression or complications such as incarceration or strangulation. 1

Mesh Selection for Clean Elective Repair

• Synthetic mesh is the standard choice for clean surgical fields in elective repair, offering superior durability and lowest recurrence rates. 1, 3
• The mesh should extend at least 3 cm beyond the defect boundaries in all directions to ensure adequate overlap and prevent recurrence. 1
• Polypropylene mesh remains the most commonly used material due to its durability and tissue compatibility. 1

Surgical Timing Strategy

Sequential vs Concurrent Approach

• The para-esophageal hernia should be addressed first or concurrently with the abdominal wall hernia, as symptomatic para-esophageal hernias carry risk of acute complications including incarceration, volvulus, and perforation. 4, 5
• If both repairs are performed concurrently, the para-esophageal repair is typically done first (via laparoscopic or open approach), followed by the abdominal wall hernia repair during the same anesthetic. 4
• Staged repair is acceptable if the patient's overall condition or operative risk necessitates it, with the para-esophageal hernia taking priority due to its symptomatic nature and acute complication risk. 5

Approach Selection

• Laparoscopic approach is preferred for both repairs when feasible, as it offers lower wound infection rates, shorter hospital stays, and allows evaluation of both defects simultaneously. 1
• For the abdominal wall hernia, laparoscopic intraperitoneal onlay mesh (IPOM) or transabdominal preperitoneal (TAPP) techniques can be employed. 1
• Open preperitoneal mesh placement is an alternative if laparoscopy is contraindicated or if the para-esophageal repair requires an open approach. 1

Critical Preoperative Optimization

Patient-Specific Considerations at Age 72

• Assess and optimize cardiopulmonary status, as this age group has higher risk of respiratory and cardiac complications, particularly with para-esophageal hernia repair. 5
• Correct any preoperative anemia with oral or intravenous iron supplementation, as anemia increases postoperative complications and transfusion requirements. 1
  • IV iron is more effective at restoring hemoglobin and decreases blood transfusion by 16% without increased adverse effects. 1
  • Delay surgery 2-4 weeks if possible to allow hemoglobin improvement. 1

Risk Stratification

• Evaluate ASA score, as ASA ≥3 is associated with increased mesh infection risk and overall morbidity. 1
• Assess for smoking status and optimize cessation, as smoking significantly increases mesh infection risk. 1

Red Flags Requiring Urgent Intervention

For the Abdominal Wall Hernia

• Sudden onset of severe pain, irreducibility, skin changes (redness, discoloration), or vomiting indicate possible strangulation requiring emergency surgery. 1
• Tachycardia ≥110 beats/min is the earliest warning sign of intra-abdominal complications and should prompt immediate evaluation. 1
• Fever ≥38°C combined with tachycardia suggests possible bowel ischemia or perforation. 1

For the Para-Esophageal Hernia

• Acute symptoms of hernia incarceration including severe epigastric pain, retching, or inability to pass nasogastric tube constitute surgical emergencies. 4, 5
• These presentations require immediate surgical intervention regardless of the abdominal wall hernia status. 5

Postoperative Management Considerations

Antimicrobial Prophylaxis

• Short-term prophylaxis only is required for clean elective repair of the abdominal wall hernia. 1, 6
• If bowel resection becomes necessary during either repair, extend prophylaxis to 48 hours. 6

Expected Outcomes

• Mesh repair of supra-umbilical hernias achieves recurrence rates of 0-4.3% with appropriate technique. 1
• Para-esophageal hernia repair outcomes are generally favorable with all surgical approaches when performed electively. 4

Critical Pitfalls to Avoid

• Never use tissue repair alone even for small abdominal wall defects, as recurrence rates are unacceptably high (19% vs 0-4.3% with mesh). 1, 2
• Do not delay repair of the symptomatic para-esophageal hernia, as emergency repair carries dramatically higher morbidity and mortality than elective repair. 5
• Avoid dismissing isolated tachycardia postoperatively, as it may be the only early sign of serious complications. 1
• Do not use hernia belts as definitive management, as they only provide temporary symptomatic relief and do not prevent complications. 1
• Ensure adequate mesh overlap (minimum 3 cm) to prevent recurrence at the hernia margins. 1