Large hiatal hernia: minimizing early and long-term complications after minimally invasive repair

Abstract

Paraesophageal Hernia (PEH) is the protrusion of the stomach and/or other abdominal viscera into the mediastinum due to an enlargement of the diaphragmatic hiatus. The treatment of PEH is challenging: On the one hand, watchful waiting carries the risk of developing acute life-threatening complications requiring an emergency operation. On the other hand, elective repair of PEH has non-negligible morbidity and mortality rates, also due to the characteristics of PEH affected patients, who are generally elder and frail. A review of the literature is presented to highlight strategies that can be adopted to minimize early and long-term complications after PEH surgical repair. The laparoscopic approach has been shown to provide reduced hospital stay, postoperative morbidity and mortality, and overall costs compared to traditional open surgery, and it is currently considered the standard approach both to elective and emergency operations. The evidence suggests that strict adherence to surgical principles, such as hernia sac excision, extended mediastinal dissection of the esophagus, and tension-free crural repair with or without mesh are mandatory to achieve optimal surgical outcomes and reduce PEH recurrence rate. Different shapes, materials, and techniques of prosthetic repair and the use of relaxing incisions have been proposed, but long-term data are lacking, and no conclusions can be drawn regarding the ideal method of crural closure. When a short esophagus is recognized despite extensive mediastinal dissection, esophageal lengthening procedures are indicated. Systematic addition of a fundoplication is strongly encouraged, for either treating gastroesophageal reflux or reducing recurrence rate.

Clinical Outcomes of a Laparoscopic Total vs a 270° Posterior Partial Fundoplication in Chronic Gastroesophageal Reflux Disease

“…This study contributes to the growing number of randomized trials with a sufficiently long follow-up period to allow firm conclusions regarding the efficacy over time of reflux control related to the design of the repair. Previous reports have often focused on the surgical reduction and repair of the hiatal hernia. Thus, it does not seem to be of major relevance whether an anterior or a posterior crural repair is performed .…”

Gastrocutaneous fistula and gastrointestinal bleeding due to left superior epigastric artery haemorrhage as a rare complication of anterior gastropexy

“…In a recent review by Ugliono et al , the authors bemoan the limited data regarding the role of anterior gastropexy without associated procedures 11. The procedure is nevertheless considered to be safe when used alongside hiatal repair,2 as the reported morbidity has been considered to be low.…”

Modern aspects of diagnosis and surgical treatment of hiatal hernias: Literature Review

“…Therefore, surgical intervention in fully asymptomatic paraesophageal hernias can be considered individually, taking into account age, concomitant pathology, the risk of surgery and the experience of the operating surgeon. All experts unanimously agree that surgical treatment is indicated for all patients with symptomatic hiatal hernia [9].…”