Laparoscopic management of giant hiatal hernia : factors influencing long-term outcome

The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate. In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. "Tension-free" repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis-Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction. There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis-Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique. To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis-Nissen procedure in such cases.