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Minimally invasive surgery: hiatal hernia repair—a narrative review

Paraesophageal hiatus hernias are a common cause of obstructive upper gastrointestinal symptoms including pain, early satiety, postprandial bloating and belching, dysphagia and regurgitation. Most such hernias are symptomatic and surgical repair should be offered. Asymptomatic paraesophageal hernias may progress to symptomatic hernias and occasionally may lead to emergency presentations. However, true asymptomatic hernias may not require repair, particularly in the elderly. Minimally invasive repair of paraesophageal hernias is a well-recognized, safe and effective operation to relieve these symptoms, and is preferable to open repair. The etiology, pathophysiology, indications for repair, required preoperative investigations and surgical technique of paraesophageal hernia repair are detailed in this article. Major steps of the operation include hernia sac excision, preservation of the vagus nerves, wide mediastinal mobilization of the esophagus, tension-free crural repair and performance of a fundoplication. Though the short-term benefits of mesh hernioplasty are well-documented, long-term evidence is lacking to support the role of reinforced crural repair and therefore this need not be performed. Expert opinion suggests that fundoplication should accompany crural repair in order to optimize reflux-related outcomes and to decrease recurrence risk, though there remains a need for further research into this topic. At least 2–3 cm of intraabdominal esophageal length should be achieved at operation and the short esophagus should be identified and corrected by means of various techniques.