Hiatal Hernia Repair with Nissen Fundoplication vs Hiatal Hernia Repair Alone
In patients with GERD and hiatal hernia, you should perform combined laparoscopic hiatal hernia repair with Nissen fundoplication rather than hiatal hernia repair alone, as fundoplication is essential to address the reflux component and prevent recurrent symptoms. 1
Rationale for Combined Approach
The fundamental principle is that hiatal hernia repair alone does not adequately address the underlying gastroesophageal reflux pathophysiology. The evidence strongly supports combining these procedures:
- Fundoplication must be performed in conjunction with hiatal hernia repair to address the reflux component, as isolated hernia repair fails to restore the anti-reflux barrier mechanism 1
- Laparoscopic Nissen fundoplication with concomitant hiatal hernia repair is the preferred surgical technique when hiatal hernia is present 2
- The combined approach provides durable relief of GERD symptoms and esophagitis, representing the gold standard treatment 3
Essential Preoperative Workup
Before proceeding with surgery, complete the following diagnostic evaluation:
- 24-hour multichannel intraluminal impedance-pH monitoring to objectively confirm pathologic GERD (this is the gold standard) 4
- High-resolution esophageal manometry to assess peristaltic function and exclude achalasia or severe motility disorders 4
- Upper endoscopy to document LA classification grade of erosive esophagitis and rule out Barrett esophagus, strictures, or malignancy 1, 4
- Barium swallow to identify the exact size of hiatal hernia, assess for short esophagus, and detect any strictures 1, 4
Surgical Technique Components
The combined procedure requires three critical elements:
- Closure of the diaphragmatic hiatus using non-absorbable sutures to repair the hernia defect 1
- Complete mobilization of the gastric fundus by dividing short gastric vessels 1
- Creation of a tension-free fundoplication wrap (360° for Nissen) around the distal esophagus 1, 4
Nissen (360°) vs Toupet (270°) Fundoplication
While both techniques can be combined with hiatal hernia repair, the choice depends on esophageal motility:
- Nissen fundoplication (360° wrap) is the gold standard for durable relief of GERD symptoms and has a lower failure rate 1, 3
- Nissen may result in more dysphagia, retching, gas bloating, and inability to belch (5-43% experience postoperative dysphagia) 5, 4
- Toupet fundoplication (270° posterior wrap) should be strongly considered if preoperative manometry shows impaired esophageal peristalsis (esophageal body peristaltic pressure <35 mmHg), as it has lower rates of postoperative dysphagia 1, 4
- Partial wraps are associated with fewer adverse effects but higher reflux recurrence rates (14% vs 8% in one series) 5, 6
Expected Outcomes and Complications
Understanding the risk-benefit profile is essential for informed consent:
- Laparoscopic approach has excellent safety with overall in-hospital mortality of 0.14% 1, 4
- Over 85% patient satisfaction with both complete and partial wrapping techniques 7
- Postoperative dysphagia is the most frequent complication, typically resolving in 4-7 weeks after Nissen and 3-5 weeks after Toupet 6
- Gas bloat syndrome occurs when patients cannot belch or vomit effectively, with associated flatulence and early satiety 4
- Recurrence rates range from 14-23% at 2-5 years, with most cases responding to PPI medication without requiring reoperation 6
Critical Pitfall to Avoid
Never perform hiatal hernia repair without fundoplication in patients with documented GERD, as this leaves the reflux pathophysiology unaddressed and leads to persistent symptoms despite anatomic correction of the hernia 1. The hiatal hernia contributes to GERD by disrupting the anti-reflux barrier, but repairing the hernia alone does not restore adequate lower esophageal sphincter function 1.