Lessons learned from revision procedures: a case series pleading for reinforcement of the anterior hiatus in recurrent hiatal hernia.

Background: Hiatal Hernia (HH) is a common structural defect of the diaphragm. Laparoscopic repair with suturing of the hiatal pillars followed by fundoplication has become standard practice. In an attempt to lower HH recurrence rates, mesh reinforcement, commonly located at the posterior site of the esophageal hiatus, has been used. However, effectiveness of posterior mesh augmentation is still up to debate. There is a lack of understanding of the mechanism of recurrence requiring further investigation. We investigated the anatomic location of HH recurrences in an attempt to assess why HH recurrence rates remain high despite various attempts with mesh reinforcement.

Methods: A retrospective case series of prospectively collected data from patients with hiatal hernia repair between 2012 and 2020 was performed. In total, 54 patients with a recurrent hiatal hernia operation were included in the study. Video clips from the revision procedure were analyzed by a surgical registrar and senior surgeon to assess the anatomic location of recurrent HH. For the assessment, the esophageal hiatus was divided into four equal quadrants. Additionally, patient demographics, hiatal hernia characteristics, and operation details were collected and analyzed.

Results: 54 patients were included. The median time between primary repair and revision procedure was 25 months (IQR 13-95, range 0-250). The left-anterior quadrant was involved in 43 patients (80%), the right-anterior quadrant in 21 patients (39%), the left-posterior quadrant in 21 patients (39%), and the right-posterior quadrant in 10 patients (19%).

Conclusion: In this study, hiatal hernia recurrences occured most commonly at the left-anterior quadrant of the hiatus, however, posterior recurrences were not uncommon. Based on our results, we hypothesize that both posterior and anterior hiatal reinforcement might be a suitable solution to lower the recurrence rate of hiatal hernia. A randomized controlled trial using a circular, bio-absorbable mesh has been initiated to test our hypothesis.