Hiatal hernia surgery requires complete phrenoesophageal membrane dissection and proper esophageal mobilization. The phrenoesophageal membrane and hernia sac must be dissected and completely resected to allow for circumferential esophageal mobilization. The esophagus must be dissected free of mediastinal adhesions until obtaining at least 3 cm of tension free intra-abdominal esophagus. The hiatus is then carefully closed with interrupted pledgeted sutures. An absorbable mesh is sometimes used to cover the repair for added reinforcement especially when the hiatal muscle is weak.
Studies have shown decreased early but not late recurrence rate with mesh placement. The key to preventing hiatal hernia recurrence and increasing its durability is first early intervention. The earlier the repair is performed in a patient life the better the outcome. Hiatal hernias increase in size with time due to chronic GERD. Reflux of acid and bile into the esophagus results in esophageal contraction and shortening. This causes the stomach to further herniate into the chest which in turn worsens GERD. This vicious cycle perpetuates the problem of GERD leading to a progressive disease that worsens with time. Esophageal shortening hinders adequate esophageal mobilization. Inadequate esophageal mobilization increases hiatal hernia recurrence rate. This is the most important factor in hiatal hernia repair. If the esophagus is brought under tension into the abdominal cavity the hiatal hernia will recur.
Most hiatal hernia revisions that we perform at Houston Heartburn and Reflux Center are associated with a poorly mobilized esophagus. Very rarely do I encounter a short esophagus following adequate mobilization. In such cases I prefer to perform a Roux-en-Y gastric bypass rather than a Collis gastroplasty. I am not a fan of the Collis gastroplasty. The idea of wrapping the gastric fundus around a tubular stomach makes no physiologic sense to me. Gastric bypass offers great protection against GERD and in revision cases I always add the possibility of gastric bypass to the surgical consent.
Reference:
Surg Endosc. 2017 Jan 11
Equal patient satisfaction, quality of life and objective recurrence rate after laparoscopic hiatal hernia repair with and without mesh.
Koetje JH, Oor JE, Roks DJ, Van Westreenen HL, Hazebroek EJ, Nieuwenhuijs VB.