Laparoscopic Surgery for Recurrent Hiatal Hernia

Background

Hiatal hernia (HH) is defined as a prolapse of part of the stomach through the diaphragmatic esophageal hiatus. This pathology is mainly observed in elderly patients (aged ≥75 years). Surgery is recommended whenever the hernia is symptomatic. Recurrence is observed in 15%–60% of cases ¹ ; however, the clinical significance of anatomical recurrence is questionable, and asymptomatic patients do not require reoperation. It is important to establish a relationship between the symptoms and recurrence. The most frequent symptoms are gastroesophageal reflux (GERD), dysphagia, early satiety, or intermittent epigastric or substernal pain. Some patients also experience respiratory symptoms, such as dyspnea or bronchospasm. ² However, recurrent HH can be diagnosed based on these symptoms; in the vast majority of cases, recurrence is asymptomatic and does not require a reoperation. It is essential to check beforehand that the symptoms are related to HH and not to some other pathology, particularly when new symptoms appear. Surgery is also indicated to manage complications, such as gastric volvulus, bleeding, obstruction, strangulation, and perforation.

During reoperation, it is necessary to restore the native anatomy, which is associated with a risk of esophageal or gastric injury. Closure of the esophageal hiatus and removal of the hernia sac are crucial steps in HH repair to prevent recurrence.

This study proposes a method for laparoscopic management of patients presenting with HH recurrence and persistent or new symptoms, and requiring reoperation.

Study Design

This study was based on recent articles published in the literature; there are no large series on repeat interventions for HH.

We made a video of laparoscopic treatment (Supplementary Video S1) of HH recurrence in a 50-year-old patient, operated on 2 years previously, where the recurrence led to frequent food blockages (as confirmed by computed tomography [CT]).

Surgical Technique

Anatomic recurrence is common, with a prevalence of ∼60% reported previously at the 12-year follow-up, ³ as indicated by barium transit or CT. These results are consistent with other mono- and multicentric series.^1,4 In the majority of cases, HH involves migration from the upper pole of the stomach, which does not always have functional consequences: the quality of life is often unaffected by anatomical recurrence. ⁴ For this reason, most authors, recommend a functional rather than anatomical assessment to determine whether reoperation is necessary, which is often difficult due to the requirement for complete dismantling of the remaining wrap as the first step of the reoperation.

The risk–benefit balance must be carefully evaluated before reoperation. Indeed, reoperation is usually performed in aged patients with comorbidities, and can be technically difficult due to postoperative adhesions and unclear anatomy. Furthermore, symptoms of recurrent hernia may occur with other apparently unrelated symptoms. Recurrence must be indicated by a CT scan or barium swallow, which are useful to rule out other diseases of the stomach and esophagogastric junction (EGJ).

In the series by Luketich et al., ⁵ general complications of an esophageal or gastric fistula, or early recurrence, were 4 times more frequent than local complications in 662 patients (overall morbidity rate of 17%). A multivariate analysis revealed that the independent risk factors for postoperative complications were age >70 years, an American Society of Anesthesiologists score of 3 or 4, and gastropexy. ⁶

Laparoscopic access is widely accepted ⁷ as the standard surgical access, although there is no grade A recommendation. However, the risk of conversion remains relatively high, at 2%–9%, ⁸ and should be anticipated before surgery. Unfortunately, there are no enough cases to set up a randomized study. In our experience, laparoscopy is always feasible, even if the first operation was performed through a laparotomy. Laparoscopy improves outcomes compared with the traditional open approach, significantly decreases 30-day perioperative complication and mortality rates, ⁹ and results in a shorter hospital stay and decreased postoperative pain. ⁸ It also provides a better view of the operating field due to the magnification of the images, allowing a more accurate dissection.

The first step of the operation is to restore the native anatomy. The stomach must be repositioned within the abdomen, the wrap must be totally dismantled, and both crura must be clearly identified. In the next step, the hiatus is closed and a complete or posterior wrap is constructed. There are two areas of controversy. The first concerns reinforcement of the hiatus with a prosthetic mesh; there is no consensus because placement of a prosthesis within proximity to the EGJ has both advantages and risks. The second is diagnosis of a short esophagus, and the consequences of the lengthening thereof through Collis gastroplasty.

This can be performed laparoscopically instead of wedge resection of the inner part of the fundus, as described by Hunter et al.^10–12 However, the indications for Collis gastroplasty are unclear; the rate of gastroplasty ranges from 0% to 50%, ¹³ which underlines the absence of any clear diagnostic criteria for a short esophagus. A short esophagus in recurrent HH tends to pull the EGJ above the hiatus. Collis gastroplasty is associated with the risk of fistula formation and postoperative GERD, as the neoesophagus is constructed with gastric wall tissue and acid-secreting mucosa. However, in the era of proton pump inhibitors, this risk is somewhat theoretical, and a quality-of-life analysis showed no difference between patients who had undergone esogastroplasty and those who had not. ¹⁴

Resection of the hernia sac is associated with a significant reduction in the rate of recurrence, ¹³ and should, therefore, be part of the routine treatment of HH. Dissection of the sac is technically easy, it can be resected or simply left attached to the EGJ.

Posterior lipomas are often observed and should be resected while taking care not to damage the posterior pneumogastric nerve (which is often in contact with the lipoma).

Closure of the hiatal orifice can be performed with or without a prosthesis. In the absence of a prosthesis, it is generally necessary to close the hiatus with posterior and anterior sutures,^15,16 possibly reinforced with Teflon pledgets. ¹⁷ In cases of a very large HH, posterior suture causes the right abutment to open longitudinally, due to the tension on the sutures. Thus, plication of the left crus can be performed if necessary.

Reinforcement mesh was introduced in an effort to reduce HH recurrence; however, its effectiveness and safety remain controversial.^18,19 Two reviews on this subject have been conducted, with largely contradictory results: a meta-analysis of three randomized trials ²⁰ showed that the use of a prosthesis reduced the risk of recurrence by a factor of four at 1 year, but the second review, based on retrospective studies ²¹ and with a longer follow-up of 15–50 months, showed that the difference in outcomes between repairs with and without a prosthesis was minimal, and may have no clinical consequences. Recent randomized clinical trials have shown that HH recurrence and symptomatic outcomes are identical between mesh reinforcement and primary suture repair. ²²

The prosthesis must be shaped into a “U” to prevent stenosis of the esophagus. The use of a nonabsorbable synthetic material in contact with the EGJ can lead to severe, and sometimes late, complications. The most serious complication is erosion of the esophageal or gastric wall, which can provide various and nonspecific symptoms, ²³ such as chest pain, dysphagia, and heart burns. This complication often requires a complex reintervention that may include an esophagectomy. Another prosthesis-related complication is pericardial tamponade, which can be fatal and increase the difficulty of fixation of the prosthesis to the diaphragm with tackers. ²⁴ Therefore, this fixation procedure should be discontinued.

Theoretically, the use of nonsynthetic absorbable biomaterial does not carry a risk of digestive erosion or dysphagia ²⁵ and could, therefore, be a viable option. However, a randomized study involving pig intestinal submucosa yielded disappointing medium- and long-term results, with anatomical and functional recurrence rates equivalent to those of the control group. ²⁶

A wrap must be systematically associated to prevent GERD. It can be either partial or total. A short wrap, 1.5–3 cm, is recommended due to lower dysphagia rate. ²⁷ Partial fundoplicature has two advantages: it minimizes the risk of postoperative dysphagia, and involves anchoring of the posterior valve to the abutments (which promotes stability of the assembly). Inserting a balloon gastrostomy tube has been proposed to enhance fixation of the stomach within the abdomen, but this procedure is rarely performed. ²⁸

Reintervention is necessary in 3%–6% of patients after fundoplication. Furnée et al. ²⁹ reported a symptomatic success rate of 70% for 144 reoperations, regardless of whether laparotomy (34%), laparoscopy (11%), or thoracotomy (54%) was performed (mean follow-up, 60 months). A recent review ³⁰ reported that the success rate after laparoscopic reintervention (85%) is higher than that after a conventional approach (78%). Dallemagne et al. ³¹ enrolled 129 consecutive patients who underwent laparoscopic redo surgery after fundoplication failure. The most frequent failure types were HH (50 patients) and slippage (45 patients). Resolution of the symptoms that led to redo surgery was achieved in 27 of 37 and 11 of 16 patients operated on for recurrence and dysphagia, respectively. Objective failure was observed in 16 of 39 patients with herniation and 6 of 22 patients with slippage. Seven patients underwent an additional surgical procedure.

Management of anatomical fundoplication failure is challenging. In this study, long-term objective and subjective assessment after laparoscopic repair revealed a high failure rate, which increased with length of follow-up. Reducing the need for redo fundoplication and increasing the success rate of at first reintervention requires a more systematic and cautious assessment of the length of the esophagus.

Conclusion

Anatomical recurrence of HH is frequent. The benefit of reoperation is only apparent when there is symptomatic, rather than anatomical, recurrence. It is necessary to thoroughly evaluate patients through barium transit and/or a CT scan. Careful patient selection and expertise in laparoscopy and esophageal/stomach surgery are required. This type of reoperation should preferably be performed in an expert center. The reoperation can be done laparoscopically, with complete dissection to restore the normal anatomy. The entire hernia sac must be resected. Hiatoplasty involves the insertion of two or three nonresorbable sutures into the crura behind the esophagus, without any tension. Anterior plication of the left abutment may be necessary when there is excessive tension on any of the diaphragmatic abutments, or when the hiatal closure appears insufficient. A prosthesis can be avoided in most cases with adequate mobilization of the abutments. The new antireflux valve is only used after restoration of normal anatomy. We recommend a 3 cm partial posterior Toupet fundoplication to limit the risk of postoperative dysphagia. The benefits and risks of the operation should be evaluated beforehand, particularly in frail or elderly individuals (aged >70 years).