Hiatal hernia repair - Chapter V: treatment of recurrent hiatal hernia

Hiatal hernia recurrence after laparoscopic repair has been reported in a significant percentage of patients, from 1.2% to 66%. Some authors have reported lower recurrence rates after mesh repair, but due to the differences in technique, type of mesh, and shape and size of the hernia, this data is still controversial. Laparoscopic repair of paraesophageal hernias yields excellent relief of symptoms and improved quality of life despite a high rate of radiographically identified recurrence. Unfortunately there is no universally accepted definition of paraesophageal hernia recurrence.

Most of the series rely on barium esophagography, endoscopy or esophageal manometry to document recurrence, with rates being quite high, reaching 66%. Nonetheless, most studies report a symptomatic recurrence rate as low as 3 – 3.5% of cases. Thus, the clinical relevance of radiographic recurrence is controversial.

A 2013 study from Johns Hopkins University (Baltimore, USA) reported a correlation between a hiatal hernia recurrence > 2 cm by barium esophagography and significant symptom worsening. Oelschlager et al. reported radiographic recurrence as the greatest vertical height of stomach ≥ 2 cm above the diaphragm.

Many studies have reported little or no difference in heartburn, regurgitation, dysphagia, chest pain or satisfaction in patients with and without radiographic recurrence of hiatal hernias. Thus, only a small percentage of patients need reoperation (around 3% in the Luketich et al. large series)

When a recurrence is radiographically and clinically diagnosed, the patient should undergo a complete preoperative evaluation. A paper from the University of Creighton group (Nebraska, USA) published in 2006 recommends a preoperative evaluation consisting of:

• 1. Esophagogram to determine the size of the hiatal hernia and the length of the esophagus.
• 2. Upper endoscopy to determine the presence or absence of cancer, Barrett’s esophagus, peptic stricture, short esophagus, gastroparesis, Cameron’s ulcer and the type and size of the hiatal hernia.
• 3. Manometry: the fundoplication pressure and relaxation should be assessed at each centimeter. Relaxation below 85% should be considered abnormal. Normal fundoplication pressure is 20-35 mmHg.
• 4. pH monitoring: performed selectively in patients with bad response to proton-pump inhibitors, or with endoscopic findings of esophagitis.

Hiatal hernia recurrence can be classified into 4 groups:

• Ia: the entire wrap along with the gastroesphageal junction migrates cephalad.
• Ib: the wrap remains below the diaphragm but the stomach and the gastroesophageal junction slip cephalad.
• II: true paraesophageal hernia.
• III: defective initial construction of the wrap using the gastric body rather than the fundus.

Patients with a surgically correctable disorder that is not responsive to aggressive medical management should be candidates for reoperation. The patient should be aware of the difficulty of the operation and of the complications associated with it. 2% to 20% conversion rates have been reported, as well as 16% to 20% of gastric perforation, 25% of pneumothorax and a low rate of reoperation, around 2%. Nonetheless, patients improve with redo surgery. It has been demonstrated in cohort studies that the laparoscopic approach to reoperative hiatal hernia repair is safe and effective.

The key steps of reoperative hiatal hernia repair are the following:

• 1. Entry – insufflation
• 2. Adhesiolysis: establishing a plane between the caudate lobe and the preaortic fascia continuing into the right crus.
• 3. Hiatal dissection.
• 4. Identification and preservation of the vagus nerves: care must be taken dissecting the 12 and 6-7 o’clock positions. The identification of the nerves on the proximal esophagus is easier than distally.
• 5. Takedown of the previous fundoplication.
• 6. Crural closure: a mesh may be necessary.
• 7. Intraoperative endoscopy: identify the true gastroesophageal junction by applying pressure with a grasper and correlating with intra-luminal findings.
• 8. Evaluation of esophageal length: lengthening procedures may be necessary if it is less than 2.5 cm.
• 9. Fundoplication.

Conclusions

Despite the lack of a universally accepted definition of hiatal hernia recurrence, most authors agree that a symptomatic patient with a hiatal hernia recurrence in esophagogram ≥ 2 cm should be considered as having a recurrent hiatal hernia. Evaluation with upper endoscopy, manometry and pH monitoring should be performed to rule out other causes of the symptoms. In patients with no other causes and with a radiographic hiatal hernia recurrence, with symptoms that do not improve despite proton pump inhibitors, surgery should be advised. Both patient and surgeon should be aware of the higher complication rate associated with reoperative surgery even though clinical outcomes are satisfactory.