Surgical Repair of Large Hiatal Hernias: Insight from a High-Volume Center

Background Laparoscopic-assisted hiatal hernia (HH) repair is safe and effective; however, it is unclear whether hernia size affects perioperative outcomes and whether a watch-and-wait strategy is appropriate for patients with asymptomatic large HHs. We aimed to investigate these issues. Methods After IRB approval, we queried our prospectively maintained database for patients who underwent primary laparoscopic HH repair at our center between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). According to the intraoperative findings, HHs were divided into four groups: small (S-HH), medium (M-HH), large (L-HH), or giant (G-HH) when the percentage of herniated stomach was 0% (sliding), < 50%, 50-75%, or > 75%, respectively. Perioperative and mid-term outcomes were analyzed. Results A total of 170 patients were grouped: S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35) with mean age of 58.5.6 +/- 11.0, 61.9 +/- 11.3, 70.7 +/- 10.3, and 72.6 +/- 9.7 years (p < 0.001), respectively. Compared to M-HH patients, L-HH patients had significantly longer hospital stays (mean 2.8 +/- 3.2 vs 1.4 +/- 0.91 days; p = 0.001) and more postoperative complications (6/20 [30.0%] vs 3/69 [4.3%]; OR 6.9, 95% CI 5.4-8.4, p < 0.001). At a mean follow-up time of 43.1 +/- 25.0 and 43.5 +/- 21.6 months for the combined S/M-HH and L/G-HH groups, GERD-Health-Related Quality of Life scores were comparable (S/M-HH: 6.5 +/- 10.9 vs L/G-HH: 7.1 +/- 11.3; p = 0.63). There was no perioperative mortality. Conclusions HHs likely grow with age, reflecting their progressive nature. Laparoscopic L-HH repair was associated with higher morbidity than M-HH repair. Thus, patients with M-HH, even if less symptomatic, should be evaluated by a foregut surgeon. Regardless of HH size, good mid- and long-term quality of life outcomes can be achieved.

Automated summary

This study investigated the impact of hernia size on perioperative outcomes and the appropriateness of a watch-and-wait strategy for patients with asymptomatic large hernias. The results showed that large hernia repairs were associated with more postoperative complications and longer hospital stays compared to medium hernia repairs. Regardless of hernia size, good mid- and long-term quality of life outcomes can be achieved.