What are the surgical approaches for repairing the different types of hiatal hernia?

Surgical Approaches for Hiatal Hernia Repair

Classification-Based Surgical Strategy

For hiatal hernias, the surgical approach and technique depend primarily on hernia type, defect size, patient stability, and esophageal motility, with laparoscopic repair being the preferred approach for stable patients across all hernia types. 1, 2

Type I (Sliding) Hiatal Hernia

• Laparoscopic Nissen fundoplication (360-degree wrap) is the standard repair for Type I hernias with normal esophageal motility (>65 mmHg peristaltic amplitude). 3
• For patients with poor esophageal motility (<65 mmHg), laparoscopic Toupet fundoplication (270-degree partial posterior wrap) should be performed to minimize postoperative dysphagia. 1, 3
• Primary crural closure with non-absorbable sutures in two layers using interrupted 2-0 or 1-0 monofilament or braided sutures is the foundation of repair. 4
• Mesh reinforcement is not typically required for Type I hernias unless the defect exceeds 8 cm or 20 cm² in area. 1

Type II (Paraesophageal) Hiatal Hernia

• Laparoscopic repair with hernia reduction, crural closure, and fundoplication is recommended for stable patients. 2, 5
• The procedure includes: complete reduction of herniated stomach, excision of the hernia sac (to prevent fluid collections and recurrence), primary crural repair with non-absorbable sutures, and fundoplication (Nissen if normal motility, Toupet if poor motility). 4, 3
• For defects >8 cm or >20 cm², mesh reinforcement is mandatory, with the mesh overlapping the hiatal edge by 1.5-2.5 cm. 1, 6
• Biological or biosynthetic meshes are preferred over synthetic meshes due to lower recurrence rates, reduced infection risk, and decreased mesh migration. 1

Type III (Mixed) and Type IV (Upside-Down Stomach) Hiatal Hernia

• Laparoscopic repair is the method of choice even for these complex large hernias, with excellent safety profiles and low mortality (0.14%). 6, 7
• The surgical steps include: complete reduction of all herniated organs, excision of the hernia sac, primary crural closure without tension, mesh reinforcement for defects >8 cm, and fundoplication. 4, 7
• Mesh reinforcement is essentially mandatory for Type III and IV hernias given their size, with mesh fixed using transfascial sutures or tackers (avoiding tacker placement near the pericardium). 1, 6
• Anterior crural reconstruction with routine anterior mesh reinforcement represents a novel approach showing promising results with 8.4% reoperation rates at 65-month follow-up. 8

Patient Stability-Based Approach

Stable Patients

• Laparoscopic approach is strongly recommended for all stable patients with hiatal hernias, regardless of type. 4, 2
• Minimally invasive repair has significantly lower morbidity (5-6%) compared to open approach (17-18%). 1

Unstable Patients

• Laparotomy is indicated for unstable patients with signs of strangulation, perforation, or hemodynamic instability. 4, 2
• Emergency repair in unstable patients carries mortality rates of 14.3-20%. 1

Critical Technical Considerations

Mesh Use Decision Algorithm

• Primary closure should always be attempted first with non-absorbable sutures. 4, 6
• Mesh is mandatory when: defect >8 cm or >20 cm² area, distance between diaphragmatic edge and chest wall exceeds 3-4 cm (tension-free principle), or primary repair would create excessive tension. 4, 1
• Never use absorbable sutures for primary repair—they are associated with 42% recurrence rates. 4, 1

Fundoplication Selection

• Nissen fundoplication (360-degree) for normal esophageal motility: 16% dysphagia <4 weeks, 0% dysphagia >6 weeks, 1.4% recurrent reflux. 3
• Toupet fundoplication (270-degree) for poor esophageal motility: 13% dysphagia <4 weeks, 0% dysphagia >4 weeks, 6.7% recurrent reflux. 3
• Fundoplication should be performed routinely during hiatal hernia repair given the high incidence (up to 62%) of postoperative gastroesophageal reflux. 6

Hernia Sac Management

• Complete excision of the hernia sac is recommended to reduce fluid collections and eliminate a potential lead point for recurrent herniation. 4, 1
• Sac excision is particularly important when colon or stomach is contained within the sac, as it allows manipulation of the sac rather than visceral contents, reducing injury risk. 4

Common Pitfalls to Avoid

• Never attempt primary closure under tension when the hiatus-to-chest-wall gap exceeds 3-4 cm—this leads to high recurrence rates. 4, 1
• Avoid absorbable sutures for crural repair—use only non-absorbable 2-0 or 1-0 sutures. 4, 1
• Do not place tackers near the pericardium due to risk of cardiac complications. 2, 6
• Incomplete sac excision can lead to symptomatic fluid collections and recurrent herniation. 4, 1

Expected Outcomes

• Postoperative complications occur in 11-25% of patients, most commonly atelectasis, surgical site infection, bleeding, respiratory failure, and ileus. 1
• Laparoscopic approach enables early hospital discharge and rapid convalescence compared to open surgery. 9, 5
• Mesh reinforcement when appropriately used results in 0% recurrence rates in large paraesophageal hernias. 3