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Ugliono et al. Mini-invasive Surg 2021;5:2 Mini-invasive Surgery
DOI: 10.20517/2574-1225.2020.93

Review Open Access

Large hiatal hernia: minimizing early and long-term
complications after minimally invasive repair

Elettra Ugliono, Fabrizio Rebecchi, Elisabetta Seno, Mario Morino

Department of Surgical Sciences, University of Torino, Torino 10126, Italy.
Correspondence to: Prof. Fabrizio Rebecchi, Department of Surgical Sciences, University of Torino, Corso A.M. Dogliotti 14,
Torino 10126, Italy. E-mail: Fabrizio.rebecchi@unito.it

How to cite this article: Ugliono E, Rebecchi F, Seno E, Morino M. Large hiatal hernia: minimizing early and long-term complications
after minimally invasive repair. Mini-invasive Surg 2021;5:2. http://dx.doi.org/10.20517/2574-1225.2020.93

Received: 28 Sep 2020 First Decision: 13 Nov 2020 Revised: 29 Nov 2020 Accepted: 9 Dec 2020 Published: 7 Jan 2021

Academic Editor: Uberto Romario Fumagalli Copy Editor: Miao Zhang Production Editor: Jing Yu

Abstract
Paraesophageal Hernia (PEH) is the protrusion of the stomach and/or other abdominal viscera into the mediastinum
due to an enlargement of the diaphragmatic hiatus. The treatment of PEH is challenging: On the one hand, watchful
waiting carries the risk of developing acute life-threatening complications requiring an emergency operation. On the
other hand, elective repair of PEH has non-negligible morbidity and mortality rates, also due to the characteristics of
PEH affected patients, who are generally elder and frail. A review of the literature is presented to highlight strategies
that can be adopted to minimize early and long-term complications after PEH surgical repair. The laparoscopic
approach has been shown to provide reduced hospital stay, postoperative morbidity and mortality, and overall
costs compared to traditional open surgery, and it is currently considered the standard approach both to elective
and emergency operations. The evidence suggests that strict adherence to surgical principles, such as hernia sac
excision, extended mediastinal dissection of the esophagus, and tension-free crural repair with or without mesh
are mandatory to achieve optimal surgical outcomes and reduce PEH recurrence rate. Different shapes, materials,
and techniques of prosthetic repair and the use of relaxing incisions have been proposed, but long-term data are
lacking, and no conclusions can be drawn regarding the ideal method of crural closure. When a short esophagus is
recognized despite extensive mediastinal dissection, esophageal lengthening procedures are indicated. Systematic
addition of a fundoplication is strongly encouraged, for either treating gastroesophageal reflux or reducing
recurrence rate.

Keywords: Hiatal hernia, paraesophageal hiatal hernia, fundoplication, complications

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0
International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long
as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made.

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