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Hiatal Hernia: Detailed Surgical Notes

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1. Classification

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2. Pathophysiology Relevant to Surgery

• The diaphragmatic crura serve as an external sphincter reinforcing the lower esophageal sphincter (LES). When disrupted by hernia, reflux barrier function is lost.
• A normal angle of His creates a physiologic flap valve. Hiatal hernia distorts this geometry, making the LES easier to open at lower intragastric pressures.
• Non-reducing hiatal hernias impair esophageal clearance dramatically: complete emptying per swallow drops from 86% (normal) to 32% (non-reducing hernia).
• Approximately 60-70% of paraesophageal hernia (PEH) patients have abnormal 24-hour pH monitoring, nearly identical to pure GERD patients.

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3. Preoperative Workup

1. Upper endoscopy - Identifies hiatal hernia size, esophagitis grade (Los Angeles classification), Barrett's esophagus, peptic stricture, delayed gastric emptying
2. Esophageal manometry - Guides choice of fundoplication type:
   • Normal motility → 360-degree Nissen fundoplication
   • Ineffective esophageal motility (Chicago Classification v4.0) → 270-degree posterior Toupet (partial) to reduce dysphagia risk
   • Must rule out achalasia and named motility disorders
3. Barium esophagram - Increases sensitivity for diagnosing hiatal hernia; essential for understanding anatomy of prior wraps; sliding hernia that does not reduce below diaphragm in upright position suggests esophageal shortening
4. 24-hour pH monitoring - Confirms pathologic reflux objectively
5. Gastric emptying study - Relevant when delayed emptying is suspected; patients with preoperative bloating should be counseled about worsening gas bloat after ARS

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4. Indications for Surgery

• Persistent symptomatic GERD despite maximal medical therapy (primary indication)
• Large paraesophageal or mixed-type hernias (types II-IV) - traditionally all recommended for repair given risk of catastrophic complications (volvulus, strangulation)
• Inability to tolerate acid suppression (uncommon true indication)
• Atypical symptoms with objectively confirmed reflux (counsel that only ~1/3 may improve)
• Contraindication to fundoplication alone: BMI ≥35 with refractory GERD - Roux-en-Y gastric bypass is preferred

• Previous hiatal hernia repair (peripheral circumferential diaphragm incision gives simultaneous exposure)
• Short esophagus (stricture, Barrett's)
• Sliding hiatal hernia not reducing below diaphragm on upright barium study
• Concomitant esophageal myotomy needed
• Associated pulmonary pathology requiring concurrent surgery
• Obesity with poor abdominal exposure

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5. Laparoscopic Nissen Fundoplication (360-degree) - Step-by-Step

Equipment

• 0- and 30-degree laparoscope
• 5- and 12-mm ports (five total)
• Veress needle, suction-irrigation
• Hook electrocautery, bipolar/ultrasonic vessel sealer
• Nathanson (or similar) liver retractor
• 52-Fr bougie
• ½-inch Penrose drain
• Laparoscopic suturing supplies
• Equipment for intraoperative upper endoscopy

Port Placement

1. Camera port - Superior and left of umbilicus, ~1/3 distance to xiphoid; optimizes hiatal visualization
2. Liver retractor port - 5-mm, right subcostal along anterior axillary line
3. Retraction port - Slightly above umbilicus, left anterior axillary line
4. Surgeon right hand port - 11-mm, 1-2 cm below costal margin at lateral rectus border; allows triangulation with camera
5. Surgeon left hand port - 5-mm, placed last after liver retraction to visualize trajectory under falciform ligament toward hiatus

Step 1 - Crural Dissection

• Divide the gastrohepatic omentum and identify the right crus of the diaphragm
• Preserve the hepatic branch of the anterior vagus nerve
• If paraesophageal hernia present: reduce hernia contents first; begin sac excision at the 2 o'clock position at the hiatus (avoids left gastric vessels that sit in the chest on the right side of the hiatus)
• Replaced left hepatic artery (from left gastric artery) present in ~25% of patients; can typically be clipped and divided after confirming a pulse in the hepatoduodenal ligament
• Incise peritoneum over the anterior right crus and develop the plane between esophagus and right crus
• Continue anteriorly; sweep esophagus and anterior vagus nerve downward away from phrenoesophageal ligament
• Divide anterior crural tissues and identify left crus
• Anterior vagus nerve often "hugs" the left crus - careful protection required
• Dissect left crus completely, including taking down the angle of His and fundus attachments to left diaphragm
• Divide short gastric vessels and posterior pancreatic vessels to completely mobilize the gastric fundus
• Create a window behind the GE junction and pass a Penrose drain around the distal esophagus for retraction

Step 2 - Esophageal Mobilization

• Mobilize the lower esophagus circumferentially into the mediastinum, targeting 3-5 cm of intra-abdominal length without tension
• Both vagus nerves must be identified and preserved throughout dissection

Step 3 - Crural Closure

• Reapproximate the crura posterior to the esophagus using interrupted nonabsorbable suture (preferred: 2-0 silk without pledgets)
• Close until the esophageal hiatus approximates the diameter of the esophagus without gaps or external compression
• A single anterior suture may be added if posterior closure angles the esophagus anteriorly as it exits the chest

Step 4 - Identifying the GE Junction

• Definitive identification is mandatory before constructing the wrap
• The fundoplication wrap must include the GE junction - this rule applies even when a Collis gastroplasty is performed

Step 5 - Fundoplication Construction

• Calibrate with a 52-Fr bougie in the esophagus
• Construct a short, loose floppy Nissen using three interrupted nonabsorbable sutures
• The wrap should be about 2 cm long
• The fundus must be mobile enough to pass freely behind the esophagus ("shoe shine" maneuver)
• Sutures incorporate the anterior and posterior fundus walls plus the esophageal musculature (not mucosa)

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6. Partial Fundoplications

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7. Open Repair of Large / Paraesophageal Hernia

• Acutely incarcerated stomach (cannot wait for laparoscopic setup)
• Cases that cannot be completed laparoscopically
• Recurrent hernia repairs

Steps:

1. Upper midline abdominal incision
2. Decompress herniated stomach with nasogastric tube if not empty
3. Dissect hernia sac from hiatal pillars, preserving fascial covering over muscle at hiatal rim
4. Complete sac removal from the mediastinum (stomach reduces into abdomen as sac is progressively dissected from the chest; this simultaneously exposes the distal esophagus)
5. Narrow the widened hiatus with posteriorly placed nonabsorbable sutures; mesh reinforcement if desired (author preference: avoid mesh - see below)
6. Add anterior hiatal sutures if necessary for adequate narrowing
7. Construct fundoplication with three nonabsorbable sutures, calibrated with 52-Fr bougie

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8. Mesh Reinforcement

• Some randomized trials show reduced early radiologic recurrence of hiatal hernia with mesh
• Other trials show no advantage, and no longer-term outcome benefit
• Risk: mesh erosion into the esophageal lumen
• Biologic mesh (acellular porcine/human dermis, porcine small intestinal submucosa) is more widely used than synthetic, but is significantly more expensive and the only RCT supporting it failed to demonstrate superiority over suture alone at 5 years
• Current preference of most experienced surgeons: primary suture cruroplasty without mesh; mesh reserved selectively for giant defects

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9. Collis Gastroplasty (Esophageal Lengthening)

1. Place bougie in esophagus
2. Mark a point approximately 3 cm below the angle of His on the stomach with electrocautery
3. Fire a 45-mm EndoGIA stapler horizontally toward the bougie at that level
4. Create a vertical staple line alongside the bougie as the assistant retracts the resected wedge laterally
5. This creates a 3-4 cm neoesophagus (tube of gastric cardia)
6. Test with methylene blue or saline to rule out staple line leak
7. Proceed with fundoplication around the neoesophagus

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10. Laparoscopic vs. Open PEH Repair

• Vertical and horizontal volvulus of the stomach makes anatomic identification (especially esophageal location) difficult
• Large sac dissection risks significant bleeding if the surgeon deviates from the correct plane (between peritoneal sac and endothoracic fascia)
• Redundant tissue at the GEJ after sac dissection (epiphrenic fat pad + hernia sac) must be excised before constructing fundoplication

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11. Outcomes

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12. Intraoperative Complications and Management

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13. Postoperative Management

• Barium swallow on postoperative day 1 (some institutions) to confirm wrap integrity
• Liquid diet advancing to soft diet over 2-4 weeks
• Counsel patients about gas bloat, hyperflatulence (common and expected)
• If symptoms recur, obtain objective pH testing before restarting PPIs (25% of symptomatic patients post-fundoplication have normal pH scores)
• Reoperation for dysphagia: occurs in 2-16% of patients; most common indication for revision surgery

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• Fischer's Mastery of Surgery, 8th ed., pp. 2711-2712
• Mulholland & Greenfield's Surgery, 7th ed., pp. 2054-2092
• Schwartz's Principles of Surgery, 11th ed., pp. 1075-1077
• Current Surgical Therapy, 14th ed., pp. 52-54