Surgical Management of Persistent or New Symptoms After Hiatal Hernia Repair

Summary

Redo foregut surgery is challenging in today's clinical practice and is fraught with increased morbidity and reportedly a lower 'success' rate than the index procedure. Here, we present a protocol for a redo hiatal hernia repair via a minimally invasive approach.

Abstract

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. These may include recurrent reflux, dysphagia, regurgitation, weight loss, or deteriorating quality of life. While nonoperative management can be pursued in some patients, reoperation may be the only option in select patients. A thorough preoperative workup, including a repeat esophagram, upper endoscopy, +/- chest computed tomography (CT) scan, manometry, pH probe, and/or gastric emptying study, is warranted to better understand the pathophysiology of the presenting symptoms. If a recurrent hernia, slipped, or migrated wrap is identified, surgery is considered. Pseudoachalasia must also be ruled out if obstructive symptoms are observed at the hiatus. Such an exhaustive workup is indeed necessary to ensure accurate diagnosis and optimal outcome. In addition, an understanding of the factors that may have led to the recurrence will increase the chances of a successful reoperation. Although a technically demanding procedure, redo hiatal hernia repair utilizing a minimally invasive approach is increasingly being employed with promising outcomes. Herein, the steps of a redo hiatal hernia repair via a minimally invasive approach will be outlined and detailed.

Introduction

Redo foregut surgery is emerging as an important challenge in modern surgical practice. "Failure of hiatal hernia repair" may occur early or late in the postoperative period. A thorough workup to understand the underlying pathology and cause of recurrent symptoms (e.g., heartburn, reflux, dysphagia, or chest pain) is essential to appropriately address the clinical problem. Failure of hiatal hernia repair in the early postoperative period (hours to days) can be attributed to poor patient selection and/or technical error. A delayed failure may be due to a recurrence either secondary to a technical failure, enlargement of the hiatus over time (both presenting as ....

Protocol

The described protocol follows the guidelines of our institution's human research ethics committee.

1. Preoperative assessment of the patient presenting with recurrent symptoms

1. Begin with a thorough history and physical exam of the patient. Elucidate the symptoms prior to the first surgery and compare them with current symptoms to better understand the underlying pathology.
   1. Whenever possible, attempt to review preoperative workup prior to index surgery, including the upper endoscopy and manometry, as it provides detailed information about the original location of the lower esophageal sphincter (L....

Results

Table 1 summarizes the most recent studies reporting outcomes of redo hiatal hernia repair^{2,8,9,10,11,12,13}. The most common reason for the failure of the initial operation is migration of the wrap in 44%-89% of cases. A majority of cases were performed.......

Discussion

With the exponential growth of hiatal hernia repair in the last few decades, there has been a dramatic increase in the number of patients presenting with recurrent or persistent symptoms. Causes of failure of the index operation may be multifactorial, but are most commonly attributed to obesity and a shortened esophagus^1,2. A thorough preoperative evaluation and diagnostic workup are necessary to identify the etiology and tailor the surgical approach. Isolating t.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Da Vinci Xi	Intuitive	K131861	the surgical robot
Vessel sealer	Intuitive	480422	used to dissect, divide small vessels
Penrose	Cardinal Health	30414-025	used to retract the esophagogastric junction
Curved bipolar dissector	Intuitive	471344	used for dissecting
SureForm stapler	Intuitive	48345B	used for performing the Collis gastroplasty
Eithobond sutures	Ethicon	https://www.jnjmedtech.com/en-US/companies/ethicon	used for reapproximating the hiatus
Biologic mesh	Cook Biotech	G51578	used to reinforce the hiatus