Adverse Outcome and Failure Following Laparoscopic Anti-reflux Surgery for Hiatal Hernia: Is One Fundoplication Better than Other?

Abstract

The management of hiatal hernia (HH) is one of the most debated in surgery. Trends regarding indications, approach (open, laparoscopic, thoracoscopic), sac excision, mesh placement, and routine performance of fundoplication have changed over time. Today, most surgeons lean to perform a laparoscopic HH repair that entails the excision of the sac, liberal use of a mesh to buttress the hiatus, and the addition of an anti-reflux procedure. The rationale of including an anti-reflux procedure is to treat coexistent reflux or to prevent the onset of “de novo” postoperative reflux [1, 2]. In fact, many studies have shown that in the majority of patients a HH is associated with symptoms—even subtle—of dysphagia, bloating, or gastroesophageal reflux disease (GERD), and that an extensive hiatal dissection could exacerbate GERD postoperatively by impairing the anatomical anti-reflux barrier [3]. Already in 1996, a work by Wo et al. [4] showed that 68% of patients with type III PEH had a history of heartburn. Interestingly, many of these patients (41%) no longer had GERD symptoms at the time the operation, and the authors attributed this finding to the flap valve created by the stomach above the gastro-esophageal junction, suggesting that, in most patients, a type III paraesophageal hernia may be an enlarging sliding hernia. A recent double-blinded randomized controlled trial by Muller-Stich et al. [5] has validated the addition of an anti-reflux procedure by showing that a fundoplication during a PEH repair results in a net improvement in patients’ symptoms with reduced acid exposure and esophagitis. However, very little has been written on which type of fundoplication should be performed in these patients based on the outcome. In general, a total fundoplication is the preferred approach in patients with GERD, as it provides a better control of reflux than a partial fundoplication [6, 7]. Conversely, recent trends have highlighted how in patients with PEH a partial fundoplication could provide—especially in the absence of preoperative manometric data—a satisfactory balance between prevention/control of GERD and prevention of postoperative dysphagia. We have set as the goal of our chapter that to provide an evidence based overview of how the type of fundoplication can affect the outcome of a hiatal hernia repair.