What is the recommended management for a large hiatal hernia?

Management of Large Hiatal Hernia

Laparoscopic surgical repair is the definitive treatment for large hiatal hernias, incorporating hernia reduction, sac excision, crural closure with non-absorbable sutures, mesh reinforcement for defects >3 cm, and fundoplication tailored to esophageal motility. 1

Initial Assessment and Indications for Surgery

Preoperative Workup Requirements

Before proceeding with surgical repair, complete the following mandatory evaluations:

• High-resolution esophageal manometry to assess peristaltic function and exclude achalasia—this directly determines the type of fundoplication 1, 2
• Upper endoscopy to document severity of esophagitis and rule out Barrett's esophagus or malignancy 1, 2
• Barium esophagram (biphasic study preferred) to define hernia size, type, anatomic landmarks, and esophageal length 1, 3
• 24-hour pH-impedance monitoring if pathologic GERD needs confirmation, particularly when symptoms are atypical 2
• CT scan with IV and oral contrast when complications are suspected (ischemia, strangulation, volvulus)—this is the gold standard for complicated hernias with 87% specificity 1, 3

When to Operate

Proceed with surgical repair in these scenarios:

• Symptomatic hernias with heartburn, regurgitation, dysphagia, chest pain, or respiratory symptoms refractory to optimized medical therapy 2, 4
• Confirmed pathologic GERD inadequately controlled with maximal PPI therapy plus lifestyle modifications 2
• Any complicated presentation: incarceration, volvulus, organ ischemia, strangulation, or massive bleeding—these require immediate emergency surgery 2, 5
• Asymptomatic large paraesophageal hernias may be offered elective repair given the 1% annual risk of acute complications, though this remains controversial and should involve shared decision-making 4, 6

Contraindications to Definitive Repair

For high-risk elderly patients with prohibitive surgical risk, consider percutaneous endoscopic gastrostomy (PEG) or gastrostomy as a palliative alternative to prevent volvulus 1

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Surgical Technique: Key Operative Steps

Approach Selection

Laparoscopic repair is the gold standard with significantly lower morbidity (0.14% in-hospital mortality), shorter hospital stays, and improved outcomes compared to open surgery 1, 2, 7, 4

The abdominal approach is strongly preferred over thoracic—historical data show that thoracic approaches resulted in postoperative gastric volvulus requiring reoperation 5

Essential Technical Components

Execute these steps in every repair:

1. Complete reduction of all herniated contents back into the abdomen 2, 4

2. Excision of the hernia sac—failure to excise the sac increases recurrence risk 2, 4, 5

3. Crural closure using interrupted non-absorbable sutures (2-0 or 1-0 monofilament) in two layers—absorbable sutures are associated with 42% recurrence rates 1, 2

4. Achieve 3 cm of intra-abdominal esophageal length—if this cannot be obtained, consider Collis gastroplasty for short esophagus 4, 5

5. Mesh reinforcement for defects >3 cm or when primary closure creates excessive tension 1

   • Use biosynthetic, biologic, or composite meshes (preferred over synthetic due to lower infection and erosion risk) 1
   • Mesh should overlap defect edges by 1.5-2.5 cm 1, 2
   • Mesh reinforcement reduces recurrence to 0% in some series versus 42% with primary repair alone 1, 8

6. Fundoplication (see algorithm below) 1, 2

7. Temporary gastropexy to prevent postoperative gastric displacement—used in 75% of patients in experienced centers 5

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Fundoplication Selection Algorithm

The choice between complete and partial fundoplication depends entirely on preoperative manometry:

Normal Esophageal Motility (≥65 mmHg peristaltic amplitude)

Perform Nissen fundoplication (360° wrap)—this is the gold standard for durable GERD symptom relief with only 1.4% recurrent reflux rate and 2% dysphagia rate beyond 4 weeks 1, 8

Impaired Esophageal Motility (<65 mmHg peristaltic amplitude)

Perform Toupet fundoplication (270° partial wrap)—this reduces postoperative dysphagia risk (0% beyond 4 weeks) while maintaining acceptable reflux control (6.7% recurrence) 1, 8

Paraesophageal Hernias Without Reflux

The evidence is mixed on whether fundoplication is mandatory:

• Perform fundoplication routinely in paraesophageal hernia repair to prevent postoperative reflux—this is a conditional recommendation based on low-certainty evidence 6
• When preoperative workup confirms no pathologic reflux and normal anatomy, some experienced surgeons perform repair without fundoplication, though recurrent reflux rates are 14% 8
• Do NOT perform preemptive anti-reflux surgery in emergency settings—focus on hernia reduction and stabilization 1

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Special Considerations and Pitfalls

Mesh Controversy

The routine use of mesh remains equivocal in the literature 6. However, practical guidance suggests:

• Use mesh for defects >8 cm or area >20 cm² to prevent recurrence 2
• Use mesh when primary closure creates tension regardless of defect size 1
• Avoid synthetic mesh due to erosion risk; prefer biologic or biosynthetic materials 1
• Proper fixation is critical—inadequate mesh fixation is a leading cause of the 25% recurrence rate 2

Recurrence Prevention

Recurrence occurs in up to 25% of cases due to preventable technical errors 2:

• Never use absorbable sutures for crural closure 2
• Ensure adequate mesh overlap (1.5-2.5 cm) and secure fixation 1, 2
• Address increased intra-abdominal pressure postoperatively through weight management 2
• Optimize nutrition to support tissue healing 2

Emergency Presentations

When patients present with acute obstruction, ischemia, or strangulation:

• Proceed immediately to emergency laparoscopic repair without delay for extensive imaging 2
• CT findings suggesting ischemia include absent gastric wall enhancement, bowel wall thickening with target sign, and lack of contrast enhancement 3
• SIRS criteria, elevated lactate, CPK, and D-dimer predict bowel strangulation 3
• Consider diagnostic laparoscopy to assess bowel viability after spontaneous reduction 3

Bariatric Surgery Patients

For obese patients with large hiatal hernia and GERD:

• Roux-en-Y gastric bypass is preferred over sleeve gastrectomy, which worsens GERD 2
• Conversion to RYGB may be appropriate for recurrent hernia after failed fundoplication in select patients 6

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Postoperative Complications

Monitor for these common complications 2:

• Atelectasis (most common)
• Surgical site infection
• Bleeding
• Respiratory insufficiency
• Ileus
• Persistent reflux (1.4-14% depending on technique)
• Chronic pain
• Cardiac injury (rare)

Avoid chest tube insertion; use tunneled indwelling catheters only in carefully selected patients 2

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Outcomes

When proper operative principles are applied:

• Excellent symptomatic relief in elective repairs 5
• 0% mortality in elective surgery versus 10% in emergency surgery 5
• 0% recurrence when all key steps are executed with mesh reinforcement 5, 8
• Low dysphagia rates (0-2% beyond 4 weeks) with appropriate fundoplication selection 8

The critical determinant of success is adherence to all key operative steps—reduction, sac excision, adequate esophageal length, non-absorbable crural closure, appropriate mesh use, and tailored fundoplication 1, 2, 4