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Page 4 of 12 Ugliono et al. Mini-invasive Surg 2021;5:2 I http://dx.doi.org/10.20517/2574-1225.2020.93

A B

Figure 1. Hernia content reduction: (A) reduction of hiatal hernia contents by gentle traction of the hernia sac; and (B) obtaining at least
2-2.5 cm of intra-abdominal esophageal length

Figure 2. During hernia sac dissection, caution must be used to prevent injury to the vagal nerves on the anterior and posterior aspect of
the esophagus, to the pleura, and to the adjacent vascular structures. White arrow, pleura; black arrow, posterior vagus nerve; asterisk,
aorta

POSTOPERATIVE COMPLICATIONS
PEH recurrence
A significant rate of recurrences after PEH repair has been reported, although patients are often
[26]
asymptomatic . “Radiological” recurrences are described in up to 20%-30% of cases, while only 5% of
[27]
patients would require surgical revision .
Several technical factors have been investigated in an attempt to reduce the rate of PEH recurrences: PEH
sac excision, the method of crural closure, the addition of an esophageal lengthening procedure, and the
addition of a gastropexy.

PEH sac excision
To reduce the risk of recurrence, complete excision of the hernia sac should be performed whenever
[28]
feasible . This fundamental step of the procedure accomplishes several objectives: first, it represents