Hiatal Hernia Repair (Hiatoplasty): Procedure, Techniques & Recovery

Overview

Hiatal hernia repair returns the stomach to the abdomen and narrows the diaphragmatic hiatus, often combined with fundoplication to prevent reflux.

Surgical Approaches

• Laparoscopic (Standard): 5 ports; reduced pain, shorter stay, faster return to diet.
• Robotic-Assisted: Enhanced suturing for complex repairs/redo cases.
• Open (Rare): Large hernia, dense adhesions, or intraoperative complications.

Key Operative Steps

1. Reduction: Mobilize and pull stomach below diaphragm.
2. Excision of Sac: Resect peritoneal hernia sac.
3. Crural Repair: Approximate diaphragmatic crura posterior to esophagus with non-absorbable sutures ± mesh (biologic/PTFE) for large defects.
4. Fundoplication (usually):
   • Nissen (360° wrap) – classic, most effective for reflux.
   • Toupet (270° posterior) – less dysphagia/gas-bloat.
   • Dor (anterior) – often with myotomy for achalasia.
5. Esophageal Lengthening (Collis gastroplasty) if short esophagus.

Postoperative Course

• Diet progression: clear liquids → full liquids → pureed → soft → regular over 2–6 weeks.
• Typical stay: 1–2 nights (laparoscopic).
• Pain: shoulder tip (referred diaphragmatic) common Day 1–2.
• Return to work: 1–2 weeks (desk), 4–6 weeks (heavy labor).

Outcomes & Complications

• Symptom resolution (heartburn, regurgitation): 85–95% at 5 years.
• Recurrence: 10–20% (mostly asymptomatic radiographic).
• Dysphagia (early, usually transient), gas-bloat syndrome, wrap migration.

Long-term success hinges on meticulous crural closure, appropriate wrap construction, and postoperative dietary adherence.