Surgical management of paraesophageal hernia

INTRODUCTION — A paraesophageal hernia is an uncommon type of hiatal hernia that mainly affects older adults, with a median age of presentation between 65 and 75 years [1-3]. Surgical management is indicated when medical management fails to control symptoms (eg, gastroesophageal reflux, dysphagia, regurgitation, anemia, dyspnea, epigastric or abdominal pain) or when there is a complication (eg, bleeding, obstruction, or gastric volvulus) [4-8].

Surgical management of a paraesophageal hernia will be reviewed here. The anatomy, physiology, types, symptoms, and diagnosis of a hiatal hernia are discussed elsewhere. (See "Hiatus hernia".)

DEFINITION — There are four types of hiatal hernias, three of which are paraesophageal hernias (figure 1). The four types of hiatal hernias can be distinguished by the hernia contents and the position of the gastroesophageal junction [9]:

●Type I or sliding hiatus hernia is characterized by the displacement of the gastroesophageal junction above the diaphragm. The stomach remains in its usual longitudinal alignment, and the fundus remains below the gastroesophageal junction.

●Type II or "true" paraesophageal hernia results from a localized defect in the phrenoesophageal membrane where the gastric fundus serves as a lead point of herniation while the gastroesophageal junction remains fixed to the preaortic fascia and the median arcuate ligament [7,8].

●Type III or "mixed" paraesophageal hernias have elements of both type I and II hernias and are characterized by both the gastroesophageal junction and the fundus herniating through the hiatus. The fundus lies above the gastroesophageal junction.

●Type IV paraesophageal hernia is associated with a large defect in the phrenoesophageal membrane and is characterized by the presence of organs other than the stomach in the hernia sac (eg, colon, spleen, pancreas, or small intestine).

More than 90 percent of hiatal hernias are sliding hernias (type I); fewer than 10 percent are paraesophageal hernias (types II, III, or IV). Of the paraesophageal types of hiatal hernias (types II, III, and IV), approximately 90 percent are mixed paraesophageal hernias (type III). (See "Hiatus hernia", section on 'Classification' and "Hiatus hernia", section on 'Pathophysiology'.)

INDICATIONS FOR SURGICAL REPAIR — Surgical repair is indicated in patients with a symptomatic or complicated paraesophageal hernia, the urgency of which depends upon the acuity of presentation [10,11]:

●Emergency repair is required in patients with acute gastric volvulus, uncontrolled bleeding, obstruction, strangulation, perforation, or respiratory compromise secondary to a paraesophageal hernia. Paraesophageal hernias that present as an emergency are associated with high mortality rates [12].

●Elective repair is required in patients with a paraesophageal hernia but subacute symptoms, such as gastroesophageal reflux disease (GERD) refractory to medical therapy, dysphagia, early satiety, postprandial chest or abdominal pain, anemia, or vomiting. Surgical repair is associated with improved symptoms and better quality of life (QOL) [13].

●Prophylactic paraesophageal hernia repair (PEHR) in asymptomatic patients is debated among experts. Although there is no consensus, most would agree that the very old or debilitated patients should not undergo surgery, while younger and healthier patients with a life expectancy of >10 years should consider surgery to prevent both the risk of acute gastric volvulus and potentially progressive symptoms.

In a theoretical study, the mortality rate from elective repair was estimated to be 1.4 percent, while the probability of developing acute symptoms that would necessitate emergency surgery was 1.1 percent [6]. The lifetime risk of developing acute symptoms requiring emergency surgery decreases exponentially with age after 65 years. However, this study was limited to patients with type I to III paraesophageal hernias; as a result, patients with type IV paraesophageal hernias should be evaluated on a case-by-case basis. (See 'Definition' above.)

Older patients have a higher incidence of paraesophageal hernia and should not be denied surgical assessment due to the perception of increased operative risk. In a retrospective study of 534 patients undergoing PEHR, age ≥80 years was associated with more postoperative complications but not severe complications (Clavien-Dindo grade ≥IIIa) (table 1); neither did patients ≥80 years of age have more readmissions or early recurrences [14].

Another study comparing outcomes of PEHR based on age showed that, compared with younger patients (mean age 58.5 years), very old patients (mean age 83 years) had an increased length of stay and a higher major morbidity rate but not a higher mortality rate, and both groups benefited from surgery with a significant improvement in their quality of life. Because of this, the authors of the study concluded that it is safe to perform laparoscopic PEHR in older adults at experienced centers [15].

PREOPERATIVE EVALUATION — For patients with a paraesophageal hernia, we elicit a history of current symptoms, previous medical therapies, and comorbid cardiac and/or pulmonary diseases. We also perform upper endoscopy, review pathology from esophageal and gastric biopsies, and obtain a video barium swallow study.

●Upper endoscopy – Prior to surgical repair, all patients diagnosed with a paraesophageal hernia should undergo endoscopic evaluation of the hernia and rule out other esophageal or gastric pathology. A hiatal hernia is best visualized endoscopically with a retroflexion maneuver (figure 2). If an organoaxial rotation (a twist along the long axis of the stomach) is present, the endoscope cannot be passed into the duodenum (figure 3).

●Barium swallow – A barium swallow can provide information regarding gastric anatomy, the length of the esophagus, and the presence of organoaxial rotation (image 1).

Esophageal manometry is performed selectively, and pH analysis is not routinely required in our practice, as these tests tend to be unreliable and difficult to perform. In a retrospective study, patients with abnormal and normal preoperative manometric studies had similar relief in chest pain, regurgitation, dysphagia, and reflux symptoms after paraesophageal hernia repair [16]. Other surgeons perform manometry if a fundoplication is planned, as this can help guide if a full 360 degree Nissen fundoplication can be tolerated, and pH study if acid reflux is the primary reason for the paraesophageal hernia repair. (See "Overview of gastrointestinal motility testing", section on 'Esophagus'.)

OPERATIVE APPROACHES — Paraesophageal hernias can be repaired transabdominally or transthoracically. Transabdominal repairs can be performed open or laparoscopically.

In our practice, we prefer laparoscopic paraesophageal hernia repair (PEHR) for most patients in both elective and emergency settings. We use the open transabdominal approach in patients who have had multiple upper abdominal surgeries in the past and reserve the transthoracic approach for patients who have failed previous open transabdominal repair(s). (See 'Recurrence' below.)

However, the three operative approaches have not been directly compared with one another in randomized trials, and the optimal operative approach to PEHR remains controversial and varies by surgeon training and preference [17-20]. In an analysis of almost 40,000 repairs from 1999 to 2008 captured by the Nationwide Inpatient Sample (NIS) database, 74, 17, and 9 percent were performed open transabdominally, transthoracically, and laparoscopically, respectively [21]. Since that time, laparoscopic repair has surpassed open transabdominal repair as the most commonly performed procedure for PEHRs. In another study of over 25,000 patients undergoing PEHR from 2010 to 2017, 91.3 percent of the repairs were performed laparoscopically. Compared with open repair, laparoscopic PEHR was associated with lower rates of reoperation, readmission, mortality, overall complications, and major complications [22].

In the NIS study mentioned above, transthoracic repair was associated with the longest hospital stay (7.8 days), the greatest need for mechanical ventilation (5.6 percent of patients), and the greatest risk of having a pulmonary embolism [21]. Laparoscopic repair was associated with the shortest hospital stay (4.5 days) and the lowest risk of requiring mechanical ventilation postoperatively (2.3 percent of patients). It is plausible that this inpatient Medicare study may have underestimated the utilization of laparoscopic PEHR and overestimated its length of stay by failing to capture patients who were discharged within 24 hours of an uncomplicated laparoscopic PEHR.

Other uncontrolled studies suggest that the mortality and morbidity rates appear lower for laparoscopic PEHR compared with other approaches. While the risk of radiographic recurrence may be higher with this approach, reoperation rates appear to be similar. (See 'Mortality and morbidity' below.)

TRANSABDOMINAL REPAIR — An open or laparoscopic transabdominal paraesophageal hernia repair (PEHR) generally involves the same sequence of steps as detailed below.

Incision — An open transabdominal PEHR is typically performed via an upper midline incision.

A laparoscopic PEHR usually requires placement of five ports in the following positions:

●The first port, used for the laparoscope, is placed approximately 14 cm distal to the xiphoid process and 3 cm to the left of the midline.

●The second and third ports, used for stomach and liver retractors, are placed lateral to the first port in the left and right midclavicular line.

●The last two ports, used for the surgeon's dissection and suturing instruments, are placed approximately 6 cm from midline under the costal margins.

Dissection of the hiatus and hernia sac — In order to prevent reherniation, a proper PEHR requires the complete dissection and removal of the hernia sac from the mediastinum, rather than the mere reduction of hernia contents from the sac.

●The dissection of the hernia sac begins with gentle reduction of any organs (eg, colon, small bowel) within the hernia sac. Care must be taken when handling these organs to avoid injury.

●Dissection of the hernia sac requires great care to avoid injury to adjacent organs (eg, mediastinal pleura, pericardium, and aortic adventitia), which could cause bleeding or pneumothorax.

●An incarcerated stomach, if present, can be friable and should be handled with care. Some experts try to reduce the stomach to facilitate dissection of the sac (picture 1); others prefer to avoid touching the stomach at the beginning of the dissection and wait for it to come down by itself when the sac is reduced.

●The dissection of the hernia sac is performed within the plane between the hernia sac and the adjacent tissues.

●The peritoneal covering of the crus on the abdominal side is preserved when dividing the gastrohepatic omentum from the right crus of the diaphragm (picture 2).

●A Penrose drain is placed around the esophagus to facilitate the dissection of the posterior portion of the hernia sac. Using gentle upward traction on the Penrose drain, the dissection begins at the right crus and proceeds posteriorly to the left crus (picture 3).

●The hernia sac must be completely removed from the mediastinum.

●Injury or transection of the vagal nerves should be avoided to reduce the risk of delayed gastric emptying.

●Dividing the short gastric vessels will increase mobilization of the stomach, facilitate a fundoplication, and improve exposure of the operative site. (See 'Fundoplication' below.)

Esophageal mobilization — Sufficient mobilization of the lower esophagus in the mediastinum ensures return of the esophagogastric junction into the abdomen along with an adequate length of intra-abdominal esophagus, which is essential for a tension-free PEHR.

●The use of electrocautery should be limited when mobilizing the esophagus since the potential risk of cautery damage to the esophagus is high.

●The esophagus must be mobilized to the level of the inferior pulmonary veins or until ≥3 cm of intra-abdominal esophagus has been freed without tension (picture 4).

●If adequate intra-abdominal esophageal length cannot be achieved with esophageal mobilization alone, an esophageal-lengthening procedure may be required. Although "true" shortened esophagus is rare (<1 percent of patients in our practice), the failure to lengthen a shortened esophagus can lead to hernia recurrence as it produces tension on the repair.

●If a 3 cm intra-abdominal esophageal length cannot be obtained with esophageal mobilization alone, we perform a Collis gastroplasty to gain additional esophageal length [23]. The Collis procedure entails the creation of a gastric tube by vertically stapling the proximal stomach from the angle of His, parallel to a large bougie placed along the lesser curvature of the stomach (figure 4 and figure 5). The newly created gastric tube becomes an extension or elongation of the native esophagus (neoesophagus) such that the new esophagogastric junction can be located intra-abdominally.

The Collis procedure was originally performed via a left thoracotomy [24] but has since been adapted for performance via thoracoscopy [25] or laparoscopy (figure 4) [26]. The laparoscopic technique is called a wedge Collis gastroplasty because a wedge of the gastric fundus needs to be resected to permit vertical placement of the stapler parallel to the lesser curvature (figure 5). (See 'Transthoracic repair' below.)

Closure of hiatal defect — After complete dissection of the esophagus, the pillars of the crura of the diaphragm are closed inferiorly and posteriorly to the esophagus. The closure of the hiatal defect is one of the most critical steps in the repair of a paraesophageal hernia. The repair must be tension free and can be performed as a primary suture repair or with mesh. We suggest against the routine use of mesh during PEHR. Our strategy for closing the hiatal defect is as follows:

●If the crural fibers are intact after dissection, the hernia defect is small, and a tension-free closure can be accomplished, we close the hiatal defect primarily with three to four interrupted nonabsorbable sutures tied intracorporeally (picture 5).

●For larger defects in which the crural fibers cannot be closed primarily, one can consider the use of relaxing incisions along the right or left crural muscle. This can facilitate closure around the esophagus. Our preference is to perform this along the right crus (picture 6) as this will often be covered by the left lateral lobe of the liver. We then would use mesh to reinforce the area of relaxation.

●If the crural fibers are disrupted during dissection, the hernia defect is large, or the crural closure is tenuous and/or under tension, we reinforce the crural closure with a biologic mesh, such as a porcine dermal matrix, a porcine small intestinal submucosa graft, or a synthetic absorbable mesh, such as poly-4-hydroxybutyrate or polyglycolic acid/trimethylene carbonate. (See "Reconstructive materials used in surgery: Classification and host response", section on 'Types of materials'.)

Compared with suture repair alone, both permanent and biologic meshes have been shown to be effective in reducing recurrences in some randomized trials [13,27-31] but not others [32]. In a 2022 meta-analysis of seven randomized trials including 735 patients, compared with suture closure alone, patients undergoing PEHR with mesh reinforcement had similar early (relative risk [RR] 0.74, 95% CI 0.26–2.07) and late (RR 0.75, 95% CI 0.27-2.08) recurrence rates [33]. Similar recurrence rates were also found when stratifying the analysis by the type of mesh utilized (absorbable and nonabsorbable). Intraoperative complications and reoperation rates were similar in both groups, but overall morbidity rate was higher after mesh repair with nonabsorbable mesh (RR 1.45, 95% CI 1.24-1.71)

In a database study of over 25,000 patients undergoing PEHR repair between 2010 and 2017, mesh placement decreased from 46.2 to 35.2 percent of the laparoscopic PEHRs. No changes in adverse outcomes were observed over that time period, and mesh placement was not associated with adverse outcomes [22].

In our practice, we use mesh selectively during PEHR because mesh can cause serious complications (eg, intraluminal mesh erosion, esophageal stenosis, dense fibrosis) and the need for reoperations (eg, esophagectomies, partial and total gastrectomies, esophageal stent placement). In a study that pooled 26 mesh-related complications from different surgeons, the rate of complications appeared to be independent of the type of mesh (eg, polypropylene, polytetrafluoroethylene [PTFE], biologic mesh) or the configuration of the mesh (eg, heart shaped, keyhole, bridge, horseshoe) used, although biologic meshes were only associated with dysphagia, not erosion [34].

Fundoplication — We suggest performing a fundoplication with PEHR. We typically perform a complete (Nissen-type) fundoplication with PEHR, except in patients with severe preoperative dysphagia, for whom we perform a partial fundoplication to minimize the potential for worsening dysphagia postoperatively. The use of preoperative manometry can be helpful in guiding this decision. (See "Surgical treatment of gastroesophageal reflux in adults", section on 'Operative techniques'.)

Both complete (Nissen) and partial fundoplications benefit patients who have preexisting symptomatic gastroesophageal reflux disease (GERD) by restoring competency to the gastroesophageal sphincter [35]. Additional reasons to consider an antireflux procedure include reducing the risk of postoperative GERD (which can occur following extensive dissection around the crura) and obviating potential symptoms that could occur if the hernia recurs [35,36].

In a randomized trial, 40 patients underwent either simple cardiophrenicopexy (ie, suturing the cardia of the stomach to the diaphragm) or fundoplication as a part of their PEHR, and those who underwent fundoplication had significantly fewer postoperative GERD symptoms at 3 and 12 months and significantly lower rates of postoperative esophagitis (17 versus 53 percent) [37]. Other postoperative complications, such as dysphagia and gas bloating, did not differ between the two groups.

Anterior gastropexy — The ideal hernia repair should result in a permanent retention of the stomach in the abdominal cavity. However, the recurrence rate following PEHR is high because of a pressure gradient resulting from the positive intra-abdominal pressure and negative intrathoracic pressure.

An anterior gastropexy (ie, fixation of the stomach to the abdominal wall) can be used to reduce the risk of gastric reherniation into the thoracic cavity. The stomach can be fixated to the abdominal wall with sutures or percutaneous endoscopic gastrostomy (PEG) tubes depending upon whether a primary PEHR has been performed.

●Anterior gastropexy with sutures – Anterior gastropexy with sutures may be performed at the end of a PEHR, although not all surgeons perform it. In a prospective series of 28 patients undergoing laparoscopic PEHR with anterior gastropexy, all patients had a normal postoperative video esophagram at 12 months and were asymptomatic, and there were no recurrences at two years [38].

●Anterior gastropexy with PEG tubes – For patients who are too frail to undergo a formal PEHR, we perform an endoscopic hernia reduction with or without laparoscopic assistance, followed by anterior gastropexy with two PEG tubes. The placement of two PEG tubes reduces the potential risk of stomach twisting around a single PEG tube (volvulus). This procedure alleviates symptoms from a paraesophageal hernia, prevents the occurrence of gastric volvulus, and does not preclude a formal hernia repair at a later time. It can also be used for patients in an emergency setting. The technique of PEG tube placement is discussed elsewhere. (See "Gastric volvulus in adults", section on 'Poor surgical candidates'.)

In our series of 11 patients, hernia reduction and intra-abdominal fixation were achieved using the flexible endoscope and double PEG tubes in nine patients and laparoscopic-assisted PEG placement in two [39]. At two years of follow-up, only one patient had a recurrence of paraesophageal hernia. In another study, 11 high-risk patients with obstructed gastric volvulus were also managed successfully with laparoscopic gastropexy [40].

Postoperative management — Patients are admitted to the hospital after undergoing a PEHR. We maintain all patients on antiemetics for the first 24 hours postoperatively to minimize this risk of postoperative nausea or vomiting, which can disrupt the hernia repair or cause early recurrences [41].

We selectively perform a barium swallow study on the first postoperative day to assess for possible esophageal leak and early hernia recurrence and to evaluate gastric emptying and motility. Patients with a longstanding paraesophageal hernia often have delayed gastric emptying after the repair, mediated by possible mechanisms of an atrophic gastric musculature or vagal neurapraxia from the dissection [42]. If the Gastrografin swallow study shows an adequate repair, patients are started on a clear liquid diet and advanced to soft solids as tolerated.

Patients are typically discharged on the first or second postoperative day after a laparoscopic PEHR. Patients who undergo open PEHR remain hospitalized until their bowel function returns, which usually occurs in approximately five days [17]. Patients are instructed to follow a low-residue diet for two to three weeks following discharge from the hospital.

TRANSTHORACIC REPAIR — Transthoracic paraesophageal hernia repair (PEHR) is advocated by some authorities as an alternative to transabdominal repair in patients with obesity, patients who have known or suspected shortened esophagus or other esophageal disease, patients who have a very large or complex hiatal hernia (eg, type IV), or patients who have failed previous transabdominal repairs.

The proponents of this technique argue that transthoracic PEHR is a more durable repair compared with transabdominal repair because it permits more accurate intraoperative assessment of the esophageal length, greater ease of performing an esophageal-lengthening procedure (eg, Collis gastroplasty) when indicated, greater ease of closing the hiatus without tension, and a better operative view in patients with obesity [43].

Given that most patients who require PEHR are older adults, we generally reserve transthoracic repair only for those who have failed or are otherwise not a candidate for transabdominal repair. (See 'Operative approaches' above.)

The steps of a transthoracic PEHR include [43]:

●The hernia is typically exposed via a posterolateral left thoracotomy via the 7^th or 8^th intercostal space. Any incarcerated hernia content is reduced into the abdomen.

The esophagus proximal to the hernia is exposed by incising the pleura along the anterior surface of the aorta and posterior to the pericardium. Dissection toward the right chest exposing the right pleura can be accomplished with blunt dissection. A Penrose drain is placed around the esophagus and vagal nerves to provide traction.

●The stomach is exposed by opening the hernia sac; any organoaxial volvulus of the stomach is reduced if present.

●The esophagogastric junction is then identified, and its relative position to the hiatus is assessed. With the lower esophagus adequately mobilized, if the esophagogastric junction remains at or above the hiatus, a shortened esophagus is diagnosed. In the two largest studies of transthoracic PEHR, 80 and 96 percent of the patients were found to have a shortened esophagus and underwent a Collis gastroplasty [44,45]. In patients with a shortened esophagus, an esophagus-lengthening procedure, such as the Collis gastroplasty, is required, or else the repair is likely to fail because the excess tension exerted on the esophagogastric junction is liable to pull it back into the chest.

●A Collis gastroplasty is the most common esophageal-lengthening procedure performed with PEHR. A large-caliber bougie is passed via the mouth into the stomach and placed along the lesser curvature. A surgical stapler is then used to create an incision from the angle of His parallel to the bougie (figure 4). The stapling creates a tubularized proximal stomach that becomes a natural extension or elongation of the esophagus. As a result, the esophagogastric junction is extended into the abdomen for approximately 5 cm. Modifications of the Collis gastroplasty have been described for performance via a thoracoscopic or laparoscopic approach (figure 5). (See 'Esophageal mobilization' above.)

●A full (Nissen-type) or partial fundoplication is usually performed at the surgeon's discretion. The wrap is often sutured to the crura with Belsey sutures to prevent slippage of the wrap.

●The crural opening is then closed around the esophagus to reconstruct the new hiatus. The proponents of transthoracic repair argue that crural closure is easier with this technique compared with laparoscopic repair because the surgeon does not have to contend with the effect of pneumoperitoneum.

●The left thoracotomy is closed.

ROBOTIC REPAIR — To date, no randomized studies comparing laparoscopic with robotic paraesophageal hernia repair (PEHR) have been performed. One retrospective study demonstrated a reduced length of stay in robotic repairs but limited data on recurrence rates [46]. Additional research is needed to determine if there is value in utilizing the robot for PEHR surgery [47].

PATIENT OUTCOMES

Mortality and morbidity

●Laparoscopic repair – The overall mortality and morbidity rates associated with laparoscopic paraesophageal hernia repair (PEHR) are low. Retrospective reviews of 662 and 354 patients undergoing a nonemergency laparoscopic PEHR reported a 30 day mortality rate of 1.7 and 0.8 percent, respectively [1,48]. Another single-center series of 352 patients reported no mortality and low major morbidity rates of 5 and 28 percent for elective and emergency cases, respectively [49]. The reported major complications include pneumonia (4.0 percent), pulmonary embolism (3.4 percent), heart failure (2.6 percent), and postoperative leak (2.5 percent) [1].

The mortality and morbidity rates are higher in patients who are ≥70 years of age, those who require emergency surgery, and those who have one or more comorbid illnesses.

•Patients who were ≥70 years of age had much higher mortality (2.4 versus 0 percent) and morbidity (24.4 versus 10.1 percent) rates compared with those who were <70 years of age [48].

•Patients undergoing an emergency repair had a higher mortality rate than those undergoing an elective procedure (7.5 versus 0.5 percent) [1].

•Patients with more comorbid illnesses (indicated by higher American Society of Anesthesiologists [ASA] grades of 3 or 4) had higher morbidity (26.0 versus 11.2 percent) and mortality rates (2.1 versus 0.4 percent) than those with fewer comorbid illnesses (ASA 1 or 2) (table 2) [48].

●Open transabdominal repair – In a retrospective study of 1005 patients who are ≥80 years of age, open transabdominal PEHR was associated with a mortality of 8.2 percent [50]. Emergency repair, which was performed in 43 percent of patients, was associated with a much higher mortality rate compared with elective repair (15.7 versus 2.4 percent) and is the sole predictor of mortality in multivariate analysis (odds ratio [OR] 7.1, 95% CI 1.9-26.3).

●Transthoracic repair – In the two largest studies, 94 and 240 patients underwent transthoracic repair of paraesophageal hernias [44,45]. The postoperative mortality and morbidity rates were 2.1 and 1.7 percent, respectively.

Quality of life improvement — Regardless of approaches, PEHRs have been shown to improve quality of life (QOL) by alleviating symptoms attributed to the hernia [13,18,51,52].

●Laparoscopic repair – A prospective study of 111 patients found laparoscopic PEHR to be associated with improved symptoms and better QOL at one and three years after surgery [13]. At one year, all 10 individual symptom QOL scores improved compared with baseline. At three years, the improvement in QOL scores of acid reflux, postprandial chest pain, vomiting, difficulty with swallowing, bloating/gas, shortness of breath, and condition satisfaction were sustained, and the overall QOL score was 50 percent higher than the baseline score.

Another study of over 300 patients reported that laparoscopic paraesophageal hernia repair resulted in significantly improved QOL as measured by the 36-Item Short Form Health Survey at both short- and long-term (two-year) intervals [53]. Additionally, Reflux Symptom Index and GERD Health-Related Quality of Life scores improved at all postoperative time points.

●Open repair – In one study of 72 patients who underwent open transabdominal repair, symptoms such as heartburn and dysphagia were improved compared with baseline [17]. The postoperative short form-36 (SF-36) scores were higher than the general population in six of eight categories and higher than the age-matched population in eight of eight categories.

●Transthoracic repair – In the two largest studies, 94 and 240 patients underwent transthoracic repair of paraesophageal hernias [44,45]. At the time of follow-up (ranging from 42 to 94 months), 80 to 86 percent of patients were symptom free or reported satisfactory results from the surgery.

Recurrence — The pressure gradient across the abdominal and thoracic cavities predisposes the patient to a recurrence after a PEHR. In an anatomical observational study of 108 patients who underwent recurrent hiatal hernia repair, most recurrences were due to stretching of the hiatus anterior (67 percent) or to the left (21 percent) of the esophagus; 12 percent were posterior [9,54]. A foreshortened esophagus contributed to 12 percent of the cases.

Interpretation of studies reporting recurrence rates is limited by different outcome measures used. In general, the rate of radiographic recurrence (assessed by a video barium esophagram) is higher than that of clinical recurrence. Most patients with a radiographic recurrence after PEHR are asymptomatic, and patients with a clinical recurrence often have symptoms that can be controlled with medications (eg, heartburn). Only a small fraction of patients will require a re-repair for complications or intractable symptoms. Although laparoscopic PEHR appears to have a higher radiographic recurrence rate than the other two approaches, most such recurrences are clinically insignificant and do not require reoperation.

●Laparoscopic repair – A meta-analysis of 13 retrospective studies reported a clinical recurrence rate of 10.2 percent (range of 3 to 33 percent) and a radiographic recurrence rate of 25 percent [55]. An esophageal-lengthening procedure (eg, Collis gastroplasty) was associated with a lower recurrence rate. (See 'Esophageal mobilization' above.)

In a review of 50 patients who underwent laparoscopic PEHR with biosynthetic mesh reinforcement and liberal use of Collis gastroplasty (42 percent) or relaxing diaphragmatic incision (4 percent), the one-year objective recurrence rate was 8 percent, and no patient who had either a Collis gastroplasty or relaxing incision developed a recurrence [56].

A review of 31 patients who had a laparoscopic PEHR reported a radiographic recurrence in 10 patients at 10 years [52]. Only two patients required a repeat PEHR within the first year after surgery; the rest were either asymptomatic or had symptoms that were managed medically.

●Open repair – The reported rates of clinical recurrence after open PEHR varied from 0 to 44 percent [2,17,19,57]. A prospective study of 72 patients undergoing an open PEHR identified radiographic recurrences in 11 patients [17]. Eight of the recurrences were <2 cm sliding hernias; none required reoperation.

●Transthoracic repair – In the two largest studies, 94 and 240 patients underwent transthoracic repair of paraesophageal hernias [44,45]. Two and four patients (2.1 and 1.7 percent) developed clinical recurrences that required a reoperation.

Reoperation — Reoperation for a symptomatic paraesophageal hernia presents a significant technical challenge, especially if mesh has been placed at the time of the initial operation. These procedures should be performed by highly experienced surgeons. If the initial approach is laparoscopic, there should be a low threshold for the reoperation to convert to an open procedure, especially in the presence of perforation, ischemia, or significant blood loss. In complex reoperative cases (eg, patients who have failed multiple transabdominal repairs), a transthoracic approach can provide an undissected plane for repair. (See 'Operative approaches' above and 'Transthoracic repair' above.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hiatal hernia".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Hiatal hernia (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Indications for paraesophageal hernia repair – Emergency surgical repair is required for acute gastric volvulus, bleeding, obstruction, strangulation, perforation, or respiratory compromise. Elective surgical repair is required for gastroesophageal reflux disease (GERD) refractory to medical therapy, dysphagia, early satiety, postprandial chest or abdominal pain, anemia, or vomiting. Prophylactic surgery in asymptomatic patients is not advised. (See 'Indications for surgical repair' above.)

●Operative approaches – Paraesophageal hernias can be repaired transabdominally or transthoracically. Transabdominal repairs can be performed open or laparoscopically. We prefer laparoscopic paraesophageal hernia repair (PEHR) for most patients in both elective and emergency settings. We use the open transabdominal approach in patients who have had multiple upper abdominal surgeries in the past and reserve the transthoracic approach for patients who have failed previous open transabdominal repair(s). However, patient preference and available local expertise weigh heavily in the choice of procedures. (See 'Operative approaches' above.)

●Transabdominal paraesophageal hernia repair – The basic tenets of transabdominal PEHR include complete mediastinal hernia sac dissection and reduction, esophageal mobilization to relocate the esophagogastric junction intra-abdominally, stable crural closure, antireflux procedure, and intra-abdominal gastric fixation. (See 'Transabdominal repair' above.)

•Esophageal mobilization and role of Collis gastroplasty – Failure to relocate the esophagogastric junction to well within the abdomen creates tension in the PEHR, which is the leading cause of recurrences. If a 3 cm intra-abdominal esophageal length cannot be obtained with esophageal mobilization alone, we perform a Collis gastroplasty procedure to gain additional intra-abdominal esophageal length. Collis gastroplasty can be performed via thoracotomy or thoracoscopic, open transabdominal, or laparoscopic approaches (figure 4 and figure 5). (See 'Esophageal mobilization' above and 'Transthoracic repair' above.)

•Role of mesh reinforcement – We suggest against the routine use of mesh during PEHR (Grade 2C). Although mesh reinforcement of crural closure during PEHR may reduce recurrences, it may also potentially cause complications such as esophageal erosion or stenosis. We use biologic mesh selectively to close the hiatal defect if the crural fibers are disrupted during dissection, the hernia defect is large, or the crural closure is tenuous and/or under tension. Otherwise, we close the hiatus opening primarily with sutures. (See 'Closure of hiatal defect' above.)

•Role of fundoplication – We suggest performing a fundoplication with PEHR (Grade 2B). A complete (Nissen-type) fundoplication is appropriate for most patients; partial fundoplication can be performed in patients with preoperative dysphagia or abnormal esophageal motility on manometry. (See 'Fundoplication' above.)

•Alternative approach to definitive hernia repair – For patients who cannot tolerate a formal PEHR, we perform an endoscopic hernia reduction with or without laparoscopic assistance followed by double percutaneous endoscopic gastrostomy (PEG) tube placement or sutured gastropexy as an anterior gastropexy. A formal PEHR can be performed later if the patient's condition improves. (See 'Anterior gastropexy' above.)

•Postoperative management – We administer antiemetics to patients in the first 24 postoperative hours to reduce the risk of postoperative emesis, which may result in disruption of the repair and early recurrence. We selectively perform a Gastrografin swallow study on the first postoperative day to assess for possible esophageal leak and early hernia recurrence and to evaluate gastric emptying and motility. (See 'Postoperative management' above.)

●Transthoracic paraesophageal hernia repair – Transthoracic PEHR is advocated by some authorities as an alternative to transabdominal repair in patients with obesity, patients who have known or suspected shortened esophagus or other esophageal disease, patients who have a very large or complex hiatal hernia (eg, type IV), or patients who have failed previous transabdominal repairs. However, because of the higher morbidity associated with a thoracotomy, we generally reserve transthoracic repair only for patients who have failed or are otherwise not a candidate for transabdominal repair. (See 'Operative approaches' above.)

●Reoperation – Operative management of recurrent paraesophageal hernias is reserved for symptomatic patients and should only be performed by highly experienced surgeons due to its complexity. (See 'Reoperation' above.)

●Patient outcomes – When performed by experienced surgeons, PEHR via any of the three approaches (laparoscopic, open transabdominal, or transthoracic) can be accomplished with low mortality and morbidity. All three procedures are equally efficacious in achieving durable relief of symptoms (eg, acid reflux or dysphagia). (See 'Patient outcomes' above.)