Surgical strategies to prevent recurrence after hiatus hernia repair

A fundamental principle in successful HH repair is the creation of a tension-free esophageal segment within the abdominal cavity [9]. When the esophagus is genuinely “short,” attempting a primary repair without addressing this underlying issue invariably leads to excessive tension on the crural repair, significantly increasing the risk of recurrence. Two primary strategies are employed to achieve adequate esophageal length: extended mediastinal dissection and esophageal lengthening procedures, primarily the Collis gastroplasty.

Extended mediastinal dissection involves mobilizing the distal esophagus from its attachments within the posterior mediastinum [10]. The goal is to free enough length of the esophagus to allow at least 2–3 cm of intraabdominal esophagus below the diaphragm, ensuring that the esophagogastric junction (EGJ) and subsequent sphincter augmentation can reside without tension in the abdominal cavity. This dissection typically extends cranially, often beyond the inferior pulmonary veins and sometimes to the level of the aortic arch, carefully mobilizing the vagal nerves alongside the esophagus. Proponents argue that a thorough, circumferential dissection is paramount to achieving adequate length and preventing recurrence [11, 12]. However, this maneuver carries inherent risks, including esophageal perforation, injury to the vagal nerves (potentially leading to delayed gastric emptying), and pneumothorax, thus necessitating a meticulous technique and a profound understanding of mediastinal anatomy [13]. Despite the risks, it is considered the initial and often sufficient step in managing apparent esophageal shortening. In this context, the advent of robotic surgical systems has provided notable technical advantages that may facilitate and enhance the safety of extended mediastinal dissection, particularly in challenging cases [14, 15]. Firstly, three-dimensional (3D) high-definition visualization provides an immersive, magnified view of the operative field, improving depth perception and allowing for more precise identification of delicate anatomical structures within the confined and often adhered mediastinal space, such as the vagal nerves and major vessels. This enhanced visualization can be particularly beneficial for distinguishing tissue planes that might be obscured or indistinct in a 2D laparoscopic view, especially in revision surgeries where adhesions are prevalent. Secondly, the articulated instruments of robotic systems provide a far greater range of motion (seven degrees of freedom) and dexterity than rigid laparoscopic instruments, mimicking the natural movements of a surgeon’s wrist. This superior articulation allows for more refined and precise dissection, enabling surgeons to carefully dissect around the esophagus and its attachments with greater control, potentially minimizing tissue trauma and reducing the risk of vital structure injury. Furthermore, the tremor filtration inherent in robotic systems eliminates physiological hand tremors, contributing to steadier and more accurate dissection. These combined advantages can make the extended, high mediastinal dissection required for esophageal mobilization substantially easier and potentially safer, contributing to a more effective tension-free repair. While direct comparative studies specifically focusing on esophageal length achieved by robotic vs. laparoscopic dissection are still lacking, the technical capabilities of robotics are intuitively beneficial for such complex maneuvers [16], and some studies suggest improved outcomes in complex or recurrent cases where meticulous dissection is paramount.

When extended mediastinal dissection proves insufficient to achieve tension-free repair, esophageal lengthening procedures, such as Collis gastroplasty [17], may become necessary. The Collis procedure involves creating a gastric tube extension of the esophagus using a linear stapler, effectively lengthening the conduit that passes through the diaphragmatic hiatus [18, 19]. This technique is typically reserved for cases of true esophageal shortening, often associated with severe reflux esophagitis, strictures, or a history of previous failed repairs. The procedure involves passing a large bore bougie (e.g., 54–60 Fr) into the stomach, then firing a linear stapler along the bougie from the greater curvature of the stomach upwards, creating a narrow “neo-esophagus.” While effective in achieving tension-free repair, Collis gastroplasty adds complexity to the operation; increases operative time; and introduces potential for staple line leaks, strictures, and the creation of an acid-producing neoesophageal segment, which may have implications for subsequent acid reflux management. Robotic platforms can also facilitate the Collis procedure by offering enhanced visualization and precise stapler manipulation, potentially improving the accuracy of gastric tube creation. Despite these complexities, for patients with true esophageal shortening, the Collis procedure is often seen as indispensable for long-term surgical success, significantly reducing the risk of recurrence attributable to tension at the repair site. However, clinical results are mixed, and the decision to perform a Collis procedure should be based on careful intraoperative assessment of tension after maximal mediastinal mobilization [20].

The anatomical defect of an HH lies in the widening or laxity of the diaphragmatic hiatus. Therefore, direct suture repair of this defect, known as crurorrhaphy, is central to surgical repair for all types of HH. However, primary suture repair alone, especially for large hiatus defects, is frequently associated with high recurrence rates, estimated between 20–40% or even higher in some series [5‐7, 21, 22], largely due to tissue fragility and tension on the suture line. To improve the durability of hiatus repair, various techniques focusing on suturing methods, mesh augmentation, and tension-relieving incisions have evolved.

Regarding specific suturing techniques, the choice of suture material and pattern can influence the repair’s longevity. Nonabsorbable sutures are generally preferred for crural approximation due to their sustained tensile strength. While interrupted sutures are commonly used to avoid the “cheese-wiring” effect that can occur with continuous sutures under tension, continuous sutures, often using barbed material, can distribute tension more evenly across the repair [23]. Some surgeons advocate for specific techniques such as figure-of-eight sutures, mattress sutures, or polytetrafluorethylen (PTFE) pledgets [24] to provide a broader grip on the crural tissue and potentially reduce suture pull-through.

Beyond achieving adequate esophageal length and reinforcing the hiatus repair, another critical strategy to prevent recurrence is to securely anchor the newly reduced EGJ within the abdominal cavity. Even if the hiatus defect is closed robustly, cranial migration of the EGJ back into the chest can lead to recurrent herniation and persistent symptoms. Anchoring techniques aim to provide a stable, long-term fixation of the stomach or EGJ to the diaphragm or surrounding structures, thereby preventing this upward displacement. The pathophysiological idea behind anchoring techniques is to create a substitute for the disrupted phrenoesophageal membrane, which is the structure that anatomically stabilizes the EGJ at the crural hiatus.

One commonly used anchoring technique is fundophrenicopexy, also known as anterior gastropexy. This maneuver was introduced in the 1950s by R. Nissen [44] and I. Boerema [45] and involves suturing the gastric fundus directly to the undersurface of the diaphragm adjacent to the hiatus. The sutures incorporate a portion of the gastric fundus and the diaphragm, creating adhesions that help to fix the fundus and, by extension, the EGJ in an intraabdominal position. This technique is relatively straightforward to perform and is often done in conjunction with a fundoplication, where the gastric wrap itself provides a robust anchor point. The intention is to prevent stomach tissue from “telescoping” through the fundoplication and to avoid migration of the EGJ through the hiatus, thereby maintaining the antireflux barrier and preventing recurrence. Different variations exist, with some surgeons advocating for multiple sutures and others focusing on specific anatomical landmarks for optimal fixation. Recent data from an RCT indicate that anterior gastropexy might indeed reduce the rate of recurrences; however, a small subset of patients needed to have the pexy stitches removed due to persistent pain [46].

Another well-established anchoring technique is the Hill procedure, or posterior gastropexy, developed by Lucius Hill in the 1960s [47, 48]. While initially conceived as an antireflux procedure focusing on restoring the competence of the cardia by reconstructing the cardiophrenic angle, its inherent mechanism of anchoring the lesser curvature of the stomach has significant implications for preventing HH recurrence. The Hill procedure involves approximating the minor-sided EGJ, including the phrenoesophageal bundles and esophagogastric wall, posteriorly to the preaortic fascia and median arcuate ligament. This complex suture configuration not only creates a correct cardiophrenic angle including a “flap valve,” but also creates a strong, durable anchor for the EGJ, thereby preventing its cranial migration [49]. The technique is technically demanding but, when performed correctly, provides robust anatomical reconstruction that addresses both reflux and hernia recurrence simultaneously. Certain authors argue that the Hill procedure offers more physiological and durable anchoring compared to anterior gastropexy alone due to its direct fixation to the strong preaortic fascia. Another inherent advantage of this technique is its applicability to the bariatric anatomy, where the fundus may be missing or physiologically inefficient for valve creation [50, 51].

Other anchoring techniques exist, often as variations or combinations of the above [52]. These might include direct esophagopexy to the diaphragm or crus or specific anchoring sutures to secure the fundoplication to the esophagus or crura to prevent wrap herniation [53‐55]. Figure 2 depicts a technique called “anatomical EGJ reconstruction”—our institution’s standard technique for HH repair. This integrated approach includes His angle restoration, modified Hill gastropexy, anterior fundoplication, and optional hiatal augmentation with a long-term absorbable mesh (Phasix ST™; Fig. 2a). The fine control and precise suturing capabilities of robotic surgical systems can be particularly advantageous in performing these procedures, especially complex ones like Hill repair, ensuring accurate tissue handling and secure knot tying in anatomically challenging areas. The ability to articulate instruments around structures and achieve optimal angles for suture placement may contribute to the long-term integrity of these crucial anchoring points. The choice of anchoring technique often depends on the surgeon’s experience, the specific anatomy of the hernia, and whether significant reflux disease is also being addressed. Regardless of the specific method, the principle of securing the EGJ below the diaphragm remains a cornerstone of preventing long-term recurrence after HH repair.

The long-term durability of hiatus repair fundamentally relies on the quality of tissue healing and collagen remodeling at the crural closure site. Recognizing that suture line failure often stems from poor tissue strength, researchers have explored biological augmentation strategies. Platelet-rich plasma (PRP) represents an innovative approach aimed at enhancing the healing process by stimulating collagen production and improving tissue integrity at the site of crurorrhaphy.

Platelet-rich plasma is an autologous blood product containing concentrated platelets, typically 3–5 times baseline levels, suspended in a small volume of plasma [56]. Platelets are well known for their role in hemostasis, but they also contain numerous alpha granules that release a potent cocktail of growth factors upon activation, thus influencing tissue proliferation. These include platelet-derived growth factor (PDGF), transforming growth factor beta (TGF-β), vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), epidermal growth factor (EGF), and serotonin [57]. When applied to a surgical site, these growth factors are believed to stimulate cell proliferation, collagen synthesis by fibroblasts, angiogenesis [58], and tissue remodeling [59], thereby potentially accelerating and improving the quality of wound healing.

In the context of HH repair, PRP is hypothesized to strengthen crural repair by promoting robust collagen deposition and tissue regeneration at the approximated diaphragmatic crura. The rationale is that by augmenting the natural healing process, the native tissue repair becomes stronger and more resistant to recurrence under the constant physiological stresses of intraabdominal pressure and diaphragmatic movement. Platelet-rich plasma can be prepared intraoperatively from the patient’s peripheral blood via centrifugation and then applied as a gel or liquid directly to the suture line or impregnated into a mesh used for reinforcement.

While PRP has gained traction in various orthopedic and soft tissue repairs, its application in HH surgery is still largely in the experimental and early clinical stages. Preclinical studies in animal models have shown promising results, demonstrating improved tensile strength and collagen content at the crural repair site when PRP is applied [60]. However, robust clinical evidence in humans remains limited. Early pilot studies and small series have reported feasibility and safety [61, 62], but large-scale randomized controlled trials demonstrating a significant reduction in recurrence rates or improved long-term outcomes in humans are currently in the recruitment phase (NCT05023174). Challenges include standardization of PRP preparation, optimal application methods, and identifying the patient populations most likely to benefit. Despite these limitations, PRP represents a fascinating area of research in HH surgery, offering a biological approach to enhancing tissue healing and potentially mitigating the mechanical weaknesses that contribute to recurrence. Continued research is essential to fully elucidate its role and efficacy in this challenging surgical field.