Laparoscopic repair of giant hiatal hernia: a narrative review

Laparoscopic repair of giant hiatal hernia (GHH) is the current standard of care. The basic tenets of the operation are reduction of hernia sac and herniated contents with extensive mediastinal dissection, to obtain at least 2 to 3 cm of intra-abdominal esophagus after reduction; tension-free closure of the hiatus; preservation of the vagus nerves; and fundoplication based on individual patient characteristics. If the esophagus is short after reduction and extensive mediastinal mobilization, i.e., less than 2 to 3 cm of intraabdominal esophagus, then a lengthening procedure is required. Although there is some general agreement on the basic tenets of the operation, several concepts have defied definition to date. The definition of a “giant” hiatal hernia is imprecise. The determination of recurrence remains unsettled. Many surgeons still use mesh reinforcement of hiatal closure despite evidence that does not support its use. Most surgeons would probably agree that operating on a patient with a symptomatic GHH is indicated, there is less concordance about how to treat truly asymptomatic or minimally symptomatic patients. This paper reviews the current state of laparoscopic repair of GHH and describes the authors’ approach to management of GHH.