What are the surgical options for hiatal hernia repair and the specific indications for each type?

Surgical Options for Hiatal Hernia Repair and Their Specific Indications

Primary Surgical Techniques

Laparoscopic Nissen fundoplication is the gold-standard operation for hiatal hernia associated with GERD, combining complete (360-degree) fundal wrap with crural repair. 1

Nissen Fundoplication (Complete 360° Wrap)

• Indicated for: Patients with normal esophageal peristaltic function and confirmed pathologic GERD who have failed optimized medical therapy 2, 1
• Technique components: Complete fundal wrap, crural closure with non-absorbable sutures, and mesh reinforcement for defects >8 cm or >20 cm² 1, 3
• Outcomes: Long-term symptom control equivalent to Toupet fundoplication, with 72% patient satisfaction at median 54-month follow-up 4

Toupet Fundoplication (Partial 270° Wrap)

• Indicated for: Patients with documented esophageal hypomotility or dysmotility on preoperative high-resolution manometry 1
• Rationale: Reduces postoperative dysphagia risk compared to complete wrap in patients with impaired peristalsis 1
• Evidence advantage: May reduce anatomical recurrence rates compared to Nissen in some studies, though patient-reported outcomes are similar 4, 5
• Long-term results: 67% satisfaction at median 25-month follow-up with no significant difference in PPI use (31% vs 26% for Nissen) 4

Mesh-Augmented Crural Repair

• Mandatory indication: Defects larger than 8 cm diameter or exceeding 20 cm² area 1, 3
• Mesh positioning: Must overlap the hiatal defect edge by 1.5–2.5 cm to ensure adequate coverage 1, 3
• Mesh type preference: Biological or biosynthetic meshes are preferred over synthetic due to lower recurrence rates, reduced infection risk, and decreased mesh migration 3
• Safety profile: No mesh-related complications reported in cohort studies, with protection against early anatomical recurrence 5
• Critical pitfall: Avoid placing tackers near the pericardium during mesh fixation to prevent cardiac complications 1

Primary Crural Closure (Without Mesh)

• Indicated for: Smaller defects (<8 cm) where tension-free closure is achievable 3
• Suture requirement: Non-absorbable sutures only; absorbable sutures are associated with higher recurrence rates 3
• Contraindication: When the gap between diaphragmatic edge and chest wall exceeds 3–4 cm, as tension increases recurrence risk 3

Specialized Surgical Approaches

Magnetic Sphincter Augmentation

• Indication: Alternative to fundoplication in select patients, typically combined with crural repair 1
• Patient selection: Requires careful evaluation and is not suitable for all hiatal hernia patients 1

Roux-en-Y Gastric Bypass

• Primary indication: Obese patients with hiatal hernia requiring anti-reflux intervention 2, 1
• Rationale: Addresses both obesity and GERD simultaneously in this population 2, 1
• Important contraindication: Sleeve gastrectomy should be avoided in patients with significant reflux symptoms, as it can exacerbate GERD 2, 1

Gastropexy with Gastrostomy

• Indication: Alternative when standard hernia repair is not feasible due to patient factors or technical limitations 1
• Role: Serves as a damage-control or palliative option 1

Transoral Incisionless Fundoplication

• Specific indication: Carefully selected GERD patients without a hiatal hernia 1
• Exclusion: Not appropriate for patients with hiatal hernia 1

Surgical Approach Selection Algorithm

Laparoscopic Approach (Preferred)

• Indication: Stable patients with elective repair 3, 6
• Advantages: Lower morbidity (5–6% vs 17–18% open), shorter hospital stay (3.4 days vs 9.1 days), equivalent long-term outcomes 3, 6
• Completion rate: Can be completed laparoscopically in >90% of cases, with 11.6% conversion rate in complex cases 6, 5

Open Laparotomy

• Indication: Unstable patients with complicated diaphragmatic hernias, acute complications (gastric volvulus, strangulation, perforation) 1, 3
• Emergency mortality: 14.3–20% mortality rate in unstable patients requiring emergency repair 3

Hernioscopy (Mixed Laparoscopic-Open)

• Specific indication: Spontaneously reduced strangulated hernias to evaluate bowel viability and prevent unnecessary laparotomy 3

Absolute Indications for Surgical Repair

Confirmed Pathologic GERD

• Requirement: Inadequate response to optimized medical therapy (PPI optimization, lifestyle modifications) 2, 1
• Mandatory preoperative testing:
  • High-resolution manometry to assess peristaltic function and exclude achalasia 2, 1
  • 24-hour ambulatory pH-impedance monitoring off PPI to confirm pathologic acid exposure 2, 1
• Critical pitfall: Never proceed without objective confirmation of pathologic GERD; this leads to poor surgical outcomes 1

Acute Hernia Complications

• Emergency indications: Acute incarceration with severe epigastric pain, retching, organ ischemia, gastric volvulus, or perforation 1, 3
• Timing: Requires urgent surgical intervention 1

Large Hiatal Hernias (≥9 cm)

• Symptomatic patients: Offer repair for GERD symptoms, respiratory complaints, anemia, or other hernia-related problems 3
• Asymptomatic patients: Consider prophylactic repair in patients <75 years in good health, as defect size alone mandates intervention 3

Essential Technical Principles

Hernia Sac Management

• Recommendation: Complete excision of the hernia sac is mandatory 3
• Rationale: Incomplete sac removal leads to fluid collections and acts as a nidus for recurrent herniation 3

Crural Closure Technique

• Suture type: Non-absorbable sutures only; absorbable sutures increase recurrence rates 3
• Tension assessment: Primary closure must not be performed under tension when hiatus-to-chest-wall distance exceeds 3–4 cm 3
• Mesh requirement: For defects >8 cm or >20 cm², mesh bridging is mandatory rather than primary closure 3

Expected Outcomes and Complications

Postoperative Complications

• Overall rate: 11–25% of patients, most commonly atelectasis, surgical-site infection, bleeding, respiratory failure, and ileus 3
• Laparoscopic vs open: Similar complication rates (9.5% vs 10.6%), but significantly shorter hospital stay with laparoscopic approach 6

Recurrence Rates

• Anatomical recurrence: 12–15% at median 24-month follow-up 5
• Symptomatic recurrence: Only 25% of anatomical recurrences are symptomatic and require reoperation 5
• Risk factors: Use of absorbable sutures, tension on closure, inadequate mesh fixation, increased intra-abdominal pressure 3

Long-Term Satisfaction

• Overall satisfaction: 95.5% satisfaction rate at median 12-year follow-up 6
• PPI use: 26–31% of patients continue PPI use postoperatively regardless of fundoplication type 4