The incidence of hiatal hernia is on the rise due to population aging and improved awareness of the disease. Laparoscopic repair is the main treatment modality; however, there remains a lack of consensus on the selection of mesh materials and operative specifications. Based on high-level evidence, this expert consensus has formulated 11 recommendations regarding the indications for mesh application, material selection, and operative methods: For patients with giant hiatal hernias (defect area >10 cm², hiatal diameter ≥ 5 cm, or over 1/3 of the gastric body entering the thoracic cavity), complex hernias, recurrent hernias, or those with weak diaphragmatic crura, mesh-reinforced repair is recommended to reduce the risk of recurrence. Synthetic meshes are suitable for giant/complex hernias; biological meshes help reduce foreign body reactions; and bioabsorbable synthetic meshes combine mechanical strength with safety. The preferred shape of the mesh is U-shaped, and fixation methods (non-absorbable sutures, absorbable staplers, or medical adhesives) are selected based on hernia size and anatomical features. For suturing the diaphragmatic crura, non-absorbable sutures are recommended, with the choice between interrupted or continuous suturing techniques tailored to patient characteristics. The method of fundoplication is determined according to esophageal pH measurement and lower esophageal sphincter pressure, and non-absorbable sutures are recommended for plication.
Humans ; Hernia, Hiatal/surgery* ; Laparoscopy/methods* ; Surgical Mesh ; Herniorrhaphy/methods*

Hiatal hernia is a common disease, which is always complicated with gastro-esophageal reflux. However, owing to restriction of diagnosis ability, the finding of hiatal hernia is still at low level in China. How to increase the finding or diagnosis of this disease and improve the life quality of patients, is an important task of radiologists and hernial surgeons. Surgery has been integrated into the therapy of hiatal hernia for a long time, but most surgeons still need to improve their recognition about its essence and the anti-reflux mechanism of lower esophagus. The purpose of surgery of hiatal hernia is not only to repair the defect, but to recover the anatomic structure and function of lower esophagus, as well as to rebuild anti-reflux barrier in stomach at the mean time. The key principle of surgery is to recover structure of GEJ, location of LES and the length of lower esophagus through fundoplication and firm fixation, which prevent it from dislocating to thoracic cavity. By adhering to the principle of this, we can combine the anatomy and function in repair of hiatal hernia, and recover and keep the anti-reflux function of LES utmost. MDT, specialized precision program and standardization will play more and more important roles in hiatal hernia therapy in the future. In this article, we made a review about the diagnosis and therapy history of hiatal hernia, as well as prospected the progress in the near future.
China ; Esophagus ; physiopathology ; Fundoplication ; Gastroesophageal Reflux ; Hernia, Hiatal ; diagnosis ; surgery ; Humans

There has been a sharp increase in the number of obese people worldwide thanks to modern prosperity in accordance with rapid industrialization and economic development. Recently, bariatric surgery has been applied actively to extremely obese patients (BMI>35 kg/m2) and presented as an alternative solution to provide not only weight loss but also a treatment for metabolic diseases such as diabetes mellitus, hypertension, and hyperlipidemia. Gastroesophageal reflux disease (GERD) is one of the most important diseases in morbidly obese patients, and many patients suffer from symptoms like epigastric pain, regurgitation, and dry cough. However, such symptoms are easy to be overlooked and studies on GERD are scarce in relation to bariatric surgery. In morbidly obese patients, high abdominal pressure leads to a pressure gradient between esophagus and stomach. This induces a hiatal hernia causing a greater likelihood of GERD. Many studies in regards to GERD were made after bariatric surgery (sleeve gastrectomy, Roux-en-Y gastric bypass, and gastric band), and various results have been presented. Studies should be carried out on pre-operative diagnosis of GERD, choice of operative method, and improvement of symptoms after the operation. Research is also needed upon bariatric operation in patients with uncontrolled GERD.
Bariatric Surgery ; Cough ; Diabetes Mellitus ; Diagnosis ; Economic Development ; Esophagus ; Gastrectomy ; Gastric Bypass ; Gastroesophageal Reflux ; Hernia, Hiatal ; Humans ; Hyperlipidemias ; Hypertension ; Metabolic Diseases ; Methods ; Obesity, Morbid* ; Stomach ; Weight Loss

OBJECTIVETo compare the efficacy and safety among laparoscopic Nissen, Toupet and Dor fundoplication in the treatment of hiatal hernia complicated with gastroesophageal reflux disease (GERD).

METHODSClinical data of 276 patients of hiatal hernia complicated with GERD undergoing operation in our hospital from December 2012 to January 2015 were retrospectively analyzed, including 149 patients of laparoscopic Nissen fundoplication (Nissen group), 41 of laparoscopic Toupet fundoplication (Toupet group), and 86 patients of laparoscopic Dor fundoplication (Dor group). Esophageal reflux status, esophageal manometry, GERD Q rating scale, and postoperative recovery were compare among the three groups.

RESULTSReflux status was improved significantly in the three groups after operation(all P<0.05),except that the efficacy in reducing reflux episodes and reflux longest time was not obvious in Toupet group(P>0.05). There were no significant differences in postoperative reflux time, acid reflux time ratio, reflux longest time ratio, DeMeester score among the three groups (all P>0.05). Pairwise comparison showed that Dor group was significantly better than Toupet group in reducing the number of reflux episode(14.36±10.58 vs. 29.83±19.71) and long-reflux (0.64±0.21 vs. 6.20±3.48)(both P<0.05), but Nissen group was better than these two groups in reducing the number of long-reflux (0.38±0.16, P<0.05). As compared to pre-operation, the postoperative esophageal sphincter pressure and residual pressure increased significantly, and the relaxation rate reduced significantly (all P<0.05), while the episode of ineffective swallowing increased significantly in Toupet group (11.25±2.04 vs. 6.36±3.26, P<0.05). The contrast in esophageal manometry between Toupet and Dor group showed that Dor group was better than Toupet group in the recovery of lower esophageal sphincter pressure (mean resting breathing) [(20.69±13.95) mmHg vs.(12.91±6.89) mmHg] and the decrease of ineffective swallowing [9.15±6.44 vs. 11.25±2.04](both P<0.05), while such results of Dor group were similar to Nissen group[(19.87±10.40) mmHg, 6.15±2.95, all P>0.05]. The GERD Q scores were significantly decreased after operation in 3 groups(Nissen group:10.94±2.20 vs.7.41±1.43, t=11.667, P=0.001; Toupet group: 10.91±2.02 vs.7.18±1.33, t=5.109, P=0.005; Dor group: 10.69±1.69 vs. 7.10±1.30, t=7.610, P=0.002). There was no significant difference in GERD Q scores among three groups (F=1.465, P=0.207). The operative time, blood loss, hospital stay and complications were not significantly different among 3 groups (all P>0.05). Follow-up period was 12-51 months (median 19 months), and no significant difference in recurrence was found [Nissen group: 2 cases (1.3%), Toupet group: 1 case (2.4%), Dor group: 1 case (1.2%), χ=0.363, P=0.834].

CONCLUSIONSIt is safe and feasible for these three laparoscopic fundoplications to the treatment of hiatal hernia complicated with GERD. But laparoscopic Nissen and Dor fundoplication are better than Toupet fundoplication in reducing the number of reflux episodes, suppressing long reflux, increasing lower esophageal sphincter pressure (mean resting respiration) and decreasing the incidence of postoperative dysphagia.

Blood Loss, Surgical ; Comparative Effectiveness Research ; Endoscopy, Gastrointestinal ; methods ; Esophageal Sphincter, Lower ; physiology ; surgery ; Fundoplication ; methods ; Gastroesophageal Reflux ; complications ; surgery ; Hernia, Hiatal ; complications ; surgery ; Humans ; Length of Stay ; Manometry ; Operative Time ; Postoperative Complications ; epidemiology ; Recurrence ; Retrospective Studies ; Treatment Outcome

Giant hiatal hernia (GHH) comprises 5% of hiatal hernia and is associated with significant complications. The traditional operative procedure, no matter transthoracic or transabdomen repair of giant hiatal hernia, is characteristic of more invasion and more complications. Although laparoscopic repair as a minimally invasive surgery is accepted, a part of patients can not tolerate pneumoperitoneum because of combination with cardiopulmonary diseases or severe posterior mediastinal and neck emphesema during operation. The aim of this article was to analyze our experience in gasless laparoscopic repair with abdominal wall lifting to treat the giant hiatal hernia. We performed a retrospective review of patients undergoing gasless laparoscopic repair of GHH with abdominal wall lifting from 2012 to 2015 at our institution. The GHH was defined as greater than one-third of the stomach in the chest. Gasless laparoscopic repair of GHH with abdominal wall lifting was attempted in 27 patients. Mean age was 67 years. The results showed that there were no conversions to open surgery and no intraoperative deaths. The mean duration of operation was 100 min (range: 90-130 min). One-side pleura was injured in 4 cases (14.8%). The mean postoperative length of stay was 4 days (range: 3-7 days). Median follow- up was 26 months (range: 6-38 months). Transient dysphagia for solid food occurred in three patients (11.1%), and this symptom disappeared within three months. There was one patient with recurrent hiatal hernia who was reoperated on. Two patients still complained of heartburn three months after surgery. Neither reoperation nor endoscopic treatment due to signs of postoperative esophageal stenosis was required in any patient. Totally, satisfactory outcome was reported in 88.9% patients. It was concluded that the gasless laparoscopic approach with abdominal wall lifting to the repair of GHH is feasible, safe, and effective for the patients who cannot tolerate the pneumoperitoneum.
Abdominal Wall ; surgery ; Aged ; Esophageal Stenosis ; etiology ; Female ; Fundoplication ; adverse effects ; methods ; Heartburn ; etiology ; Hernia, Hiatal ; diagnosis ; surgery ; Humans ; Laparoscopy ; adverse effects ; methods ; Male ; Middle Aged ; Pneumoperitoneum, Artificial ; adverse effects ; Postoperative Complications

INTRODUCTIONThe prevalence of hiatal hernias and para-oesophageal hernias (PEHs) is lower in Asian populations than in Western populations. Progressive herniation can result in giant PEHs, which are associated with significant morbidity. This article presents the experience of an Asian acute care tertiary hospital in the management of giant PEH and parahiatal hernia.

METHODSSurgical records dated between January 2003 and January 2013 from the Department of Surgery, Changi General Hospital, Singapore, were retrospectively reviewed.

RESULTSTen patients underwent surgical repair for giant PEH or parahiatal hernia during the study period. Open surgery was performed for four patients with giant PEH who presented emergently, while elective laparoscopic repair was performed for six patients with either giant PEH or parahiatal hernia (which were preoperatively diagnosed as PEH). Anterior 180° partial fundoplication was performed in eight patients, and mesh reinforcement was used in six patients. The electively repaired patients had minimal or no symptoms during presentation. Gastric volvulus was observed in five patients. There were no cases of mortality. The median follow-up duration was 16.3 months. There were no cases of mesh erosion, complaints of dysphagia or recurrence of PEH in all patients.

CONCLUSIONGiant PEH and parahiatal hernia are underdiagnosed in Asia. Most patients with giant PEH or parahiatal hernia are asymptomatic; they often present emergently or are incidentally diagnosed. Although surgical outcomes are favourable even with a delayed diagnosis, there should be greater emphasis on early diagnosis and elective repair of these hernias.

Adult ; Aged ; Digestive System Surgical Procedures ; methods ; Elective Surgical Procedures ; Female ; Hernia, Hiatal ; diagnostic imaging ; surgery ; Humans ; Laparoscopy ; Male ; Middle Aged ; Retrospective Studies ; Singapore ; Surgical Mesh ; Tertiary Care Centers ; Treatment Outcome

OBJECTIVETo evaluate the application of biological mesh in laparoscopic anti-reflux procedure for gastroesophageal reflux disease (GERD).

METHODSThe clinical data of 20 consecutive GERD patients underwent anti-reflux surgery in Sir Run Run Shaw Hospital from December 2012 to April 2014 were retrospectively analyzed. The laparoscopic hiatal repair with 360 fundoplicaiton was performed and the biological mesh (BiodesignTM, Surgsis) was implanted for reinforcement of hiatal repair.

RESULTSAll laparoscopic procedures were successful, no conversion and no intra-operative complications occurred. The pre-operative complains were relieved in all patients, and no recurrence was observed during 3-18 month of follow-up. Six patients got dysphagia after operation; 5 of them were controlled through medication and psychological induction; 1 received esophageal dilatation by bougie.

CONCLUSIONThe application of biological mesh in laparoscopic anti-reflux procedure for gastroesophageal reflux disease is satisfactory.

Fundoplication ; Gastroesophageal Reflux ; surgery ; Hernia, Hiatal ; surgery ; Humans ; Laparoscopy ; methods ; Recurrence ; Retrospective Studies ; Surgical Mesh

Hernia, Hiatal ; diagnosis ; pathology ; surgery ; Humans ; Male ; Middle Aged ; Omentum ; Tomography, X-Ray Computed

OBJECTIVEThrough reviewing the surgical experience in the treatment of sliding hiatus hernia, the effectiveness of Nissen fundoplication using intraoperative oesophageal manometry has been evaluated.

METHODSThere were 84 undergoing the transabdominal surgery who have been divided into three groups: 27 patients were in the Nissen group, 39 in the floppy Nissen group, 18 in the intraoperative-oesophageal-manometry group.

RESULTSThere is no postoperative death. Complications occurred in 5 patients within one month after operation: in the Nissen group, 2 patients suffered from severe dysphagia and 1 from regurgitation; In the floppy Nissen group, 2 patients had regurgitation; In the intraoperative-oesophageal-manometry group, there were no one suffering severe dysphagia or regurgitation. During the long-term follow-up, excellent functional results were also observed in the intraoperative-oesophageal-manometry group, whereas 2 patients suffered from severe dysphagia and 1 from nausea in the Nissen group and 1 patient recurred in the floppy Nissen group.

CONCLUSIONSThe Nissen fundoplication (NF) should be suitable to be done in patients with sliding hiatus hernia. But if there are possibilities to perform intraoperative oesophageal manometry during the operation of anti-reflux, side effects can be decreased to the least. Intraoperative manometry is useful in standardizing the tightness of the wrap in NF. And it will contribute to reducing or avoiding the happening of complications.

Adult ; Aged ; Esophagus ; pathology ; physiopathology ; Female ; Follow-Up Studies ; Fundoplication ; Hernia, Hiatal ; surgery ; Humans ; Male ; Manometry ; methods ; Middle Aged ; Monitoring, Intraoperative ; Postoperative Complications ; prevention & control ; Treatment Outcome

OBJECTIVETo investigate the long-term outcomes of various antireflux procedures for gastroesophageal reflux disease (GERD).

METHODSBetween November 1988 and January 2004, 129 patients with GERD underwent antireflux procedures. Six kinds of antireflux procedures were performed including Nissen fundoplication, cardiac oblique invagination (COI) procedure, Belsey Mark IV, Toupet, Thal and Dor procedures. One hundred and sixteen patients were followed up. Esophageal manometry study was carried out in 95 patients preoperatively and 51 postoperatively. 24-hour esophageal pH monitoring were carried out in 56 patients preoperatively and 35 postoperatively. Esophagoscopy were performed in all patients before operation and 48 cases after operation.

RESULTSClinical symptom scores reduced significantly from 4.1 +/- 0.4 before surgery to 1.1 +/- 1.0 after surgery (t = 27.21, P < 0.01). The outcome of surgery showed excellent in 42 cases (36.2%), good in 60 (51.7%), fair in 7 (6.0%), poor in 7 (6.0%). The long-term follow-up showed excellent or good results in 87.9% of patients. There was no significant difference in Nissen fundoplication, COI procedure and Belsey Mark IV.

CONCLUSIONSThere are significant differences in symptom score, esophageal manometry, 24-hour esophageal pH monitoring and esophagoscopy pre- and post-operatively. There is no significant difference in Nissen fundoplication, COI procedure and Belsey Mark IV.

Adolescent ; Adult ; Aged ; Aged, 80 and over ; Female ; Follow-Up Studies ; Fundoplication ; Gastroesophageal Reflux ; etiology ; surgery ; Hernia, Hiatal ; complications ; surgery ; Humans ; Male ; Middle Aged ; Retrospective Studies ; Treatment Outcome