Laparoscopic repair of large hiatal hernias

Abstract

Background: The repair of large hiatal hernias can be technically challenging. Most series describing laparoscopic repair report only symptomatic outcomes and the true recurrence rate, including asymptomatic recurrence, is not well documented. This study evaluated the long-term outcome of laparoscopic repair of large hiatal hernias.Methods: All patients who had undergone laparoscopic repair of a large hiatus hernia (more than 50 per cent of the stomach in the hernia) with a minimum 2-year clinical follow-up were identified from a prospectively maintained database. A standardized questionnaire was used to assess symptoms and a barium swallow radiograph was performed to determine anatomy. Multivariate analysis was used to identify factors associated with recurrence.Results: Of 100 eligible patients, clinical follow-up was available in 96. Follow-up ranged from 2 to 8 (median 4) years. In patients with preoperative reflux symptoms, there were significant improvements in heartburn and dysphagia scores after surgery. Overall, 80 per cent of patients rated their outcome as good or excellent. Sixty patients underwent a postoperative barium meal examination that identified 14 radiological hernia recurrences (eight small, three medium and three large). Four other patients in this group of 60 had previously undergone reoperation for early and late recurrence (two of each), giving an overall recurrence rate of 18 of 60 (30 per cent). One third of patients with recurrence were totally asymptomatic and the presence of postoperative symptoms did not reliably predict the presence of anatomical recurrence. Younger age and increased weight at operation were independent risk factors contributing to recurrence. Conclusions: Laparoscopic repair of large hiatal hernias yields good clinical outcome. Recurrence after laparoscopic repair seems to be more common than previously thought. Objective anatomical studies are required to determine the true recurrence rate. The majority of recurrences are not large and do not cause significant symptoms.

Quality of Life Following Repair of Large Hiatal Hernia is Improved but not Influenced by Use of Mesh: Results From a Randomized Controlled Trial

“…Previous reports from randomized trials 13,14,15,23 , and other studies 4,6,10 have all focussed on clinical and objective outcome parameters. However, quality of life is an alternative patient reported outcome, which reflects the general well-being and the functional status of patients.…”

Giant Hiatus Hernia and Association with Gastro-Oesophageal Reflux: A Review

“…These symptoms can include recurrent reflux, dysphagia, chest pain, nausea and bloating [46]. If thorough radiological assessment is performed, a recurrent HH has been defined in 15% to 42% of patients (median 22%) [1,13,36,37,41]. Wang, et al reported a prospective study looking at the clinical significance of asymptomatic recurrences and found that 35.7% of patient had a radiological recurrence [47].…”

“…Radiological recurrence is typically not to the same extent as the originally repaired GHH. Mostly these are small axial asymptomatic, hernias of less than 2 cm in length, of which the clinical importance is likely to be trivial [1,41]. In patients who only have recurrent reflux following a HH repair, medical management provides good symptomatic relief in the majority without ment in cardiac function [42].…”

“…Laparoscopic repair is the standard approach in most centres, however advanced laparoscopic skills are required [1,41]. Operative mortality in series from centres with an interest in the disease is reported to be 0% to 2%, with operative morbidity between 13% to 16% [1,3,35,37].…”

“…The hernia typically contains the stomach to varying degrees but may include other organs such as the omentum, colon, liver, pancreas and spleen. The term "Giant Hiatus Hernia" (GHH) has been variably defined, but most authors refer to at least 30% of the stomach, with or without other abdominal viscera, protruding through the oesophageal hiatus of the diaphragm into the mediastinum [1][2][3][4][5][6]. Symptoms arise due to dysfunction of reported to be between 8-80% [20,21,23,24].…”