Should an asymptomatic 9‑cm hiatal hernia be repaired?

Should a 9 cm Hiatal Hernia Be Repaired?

A 9 cm hiatal hernia should be repaired surgically if the patient is symptomatic or has confirmed gastroesophageal reflux disease, regardless of symptom severity. For truly asymptomatic patients, watchful waiting is appropriate given the low rate (1% per year) of developing symptoms or acute complications. 1

Decision Algorithm for 9 cm Hiatal Hernia

Symptomatic Patients

• Surgery is indicated for any patient with a 9 cm hiatal hernia who has symptoms of GERD, respiratory symptoms, anemia, or other hernia-related complaints 2, 1
• The large size (9 cm) places this hernia in the category requiring mesh reinforcement during repair, as defects >8 cm or >20 cm² should be bridged with mesh rather than closed primarily 3, 2, 4
• Laparoscopic repair is the preferred approach in stable patients, offering lower morbidity (5-6%) compared to open repair (17-18%) 2

Asymptomatic Patients

• Watchful waiting is appropriate for truly asymptomatic patients, as the risk of developing acute complications (gastric volvulus, incarceration, strangulation) is only 1.2% per patient per year 1, 5
• However, consider prophylactic repair in patients younger than 75 years who are in good overall condition, as the risk-benefit ratio favors intervention in this population 5
• Beyond age 75, individualize the decision based on surgical risk, comorbidities, and patient preference, as acute complications requiring emergency surgery carry significantly higher mortality (14.3-20%) 3

Surgical Technique Considerations

Essential Operative Steps

• Complete reduction of herniated contents and excision of the hernia sac (associated with lower recurrence rates) 6, 5
• Mesh reinforcement is mandatory for a 9 cm defect, with the mesh overlapping the defect edge by 1.5-2.5 cm 3, 2, 4
• Biological or biosynthetic meshes are preferred over synthetic meshes due to lower recurrence rates, higher resistance to infection, and lower risk of displacement 3
• Fundoplication should be performed (Nissen or Toupet) to address the high incidence (up to 62%) of gastroesophageal reflux after repair 4
• Crural closure with mesh reinforcement and achieving 3 cm of intraabdominal esophageal length 1

Common Pitfalls to Avoid

• Avoid using absorbable sutures for primary repair, as this is associated with higher recurrence rates 3
• Avoid tackers near the pericardium due to risk of cardiac complications 4, 7
• Do not attempt primary closure under tension if the distance between the diaphragm edge and chest wall exceeds 3-4 cm 3
• Incomplete sac excision may lead to fluid collections and serve as a lead point for recurrent herniation 3

Expected Outcomes

Morbidity and Mortality

• Laparoscopic repair has excellent safety with in-hospital mortality of only 0.14% in stable patients 4
• Postoperative complications occur in 11-25% of cases and include atelectasis (most common), surgical site infection, bleeding, respiratory failure, and ileus 3, 2
• Emergency repair in unstable patients carries significantly higher mortality (14.3-20%) 3

Recurrence Rates

• Anatomic recurrence can be as high as 60% at 12 years, but most recurrences are asymptomatic and do not affect quality of life 5
• Proper technique with mesh reinforcement, complete sac excision, and fundoplication reduces symptomatic recurrence to approximately 9% 6

Special Considerations

For patients with acute complications (gastric volvulus, strangulation, perforation), immediate emergency repair is mandatory regardless of hernia size, as gastric ischemia leading to perforation is the main cause of mortality 8, 9, 5

The presence of a large 9 cm hernia represents a more severe manifestation of GERD, and even if currently asymptomatic, these patients warrant close monitoring with consideration for pH-impedance testing to document reflux 2