Laparoscopic Repair of Large Hiatal Hernia Without the Need for Esophageal Lengthening With Low Morbidity and Rare Symptomatic Recurrence

The aim of this study was to assess symptomatic recurrence in patients who underwent a laparoscopic repair of large hiatal hernia without an esophageal lengthening procedure. Patients who underwent a laparoscopic repair of a large hiatal hernia from September 2009 to September 2015 by a single surgeon were identified in the retrospective review. The patients were followed up prospectively by the operating surgeon using a structured questionnaire, administered by telephone, to assess the symptoms. Symptomatic recurrence was defined as the requirement for a reoperative procedure for symptomatic recurrent hiatal hernia. There were 215 laparoscopic repairs. Reoperations (n = 35) and type I hernias of <4 cm (n = 49) were excluded. The study population included 131 patients: 36 had type I hernia, 4 had type II hernia, 37 had type III hernia, and 54 had type IV hernia. There were 102 women and 29 men, aged 63 (56-74) years. For repair, 102 Toupet, 28 Nissen, and 1 Dor fundoplications were performed. The duration of the operation was 138 (119-172) minutes. Adequate esophageal length was obtained by mediastinal esophageal mobilization in all patients, without Collis gastroplasty. A mesh was used in 106 patients. There was 1 conversion and 2 delayed esophageal leaks. The length of stay was 2 (1-3) days. Perioperative complications included atrial fibrillation in 5 patients, gastric distension or ileus in 5 patients, reintubation in 3 patients, heparin-induced thrombocytopenia in 1 patient, and temporary dialysis in 1 patient. There was no 30-day or in-hospital mortality. The questionnaire was completed by 99 out of 131 patients (76%) at 24 (9-38) months; of the 99 patients, 85 (86%) were free of preoperative symptoms; 91 (92%) were satisfied with the operation; and 73 (74%) were off proton pump inhibitors. Reoperation for symptomatic recurrent hiatal hernia occurred in 8 of the 99 patients (8%), 2 in the perioperative period and 6 at 25 (8-31) months. Laparoscopic repair of large hiatal hernia can be performed with low morbidity and results in excellent patient satisfaction. Tension-free, intra-abdominal esophageal length can be achieved laparoscopically without Collis gastroplasty. Reoperation for symptomatic recurrence is rare.