Abstract
Laparoscopic-assisted hiatal hernia (HH) repair has been reported to be safe and feasible. However, uncertainty exists regarding whether asymptomatic large HHs (L-HH) should be treated or if a watch-and-wait strategy should be used. The latter might expose the patient to the risk of progression and gastric incarceration. In this study, we investigated this issue by analyzing perioperative outcomes of patients who underwent HH repair at our high-volume center.
Methods
After obtaining approval from the Institutional Review Board, we queried a prospectively maintained database for data on patients who underwent primary minimally invasive HH repair between August 2016 and December 2019. All procedures were performed by a single surgeon (SKM). Hernias were classified in 4 groups: small (S-HH [sliding]), moderate (M-HH [<50% herniated stomach]), large (L-HH [50%–75% herniated stomach]) and giant (G-HH [≥75% herniated stomach]). Data on preoperative assessment, surgical procedure, and postoperative morbidity were analyzed and compared across groups. Complications were defined according to the Clavien-Dindo (CD) classification.
Results
In total, 170 patients met inclusion criteria. Mean age was 58.5 ± 11, 61.9 ± 11.3, 70.7 ± 10.3, and 72.6 ± 9.7 years for S-HH (n = 46), M-HH (n = 69), L-HH (n = 20), and G-HH (n = 35), respectively (p < 0.001). The mean operative time (minutes) increased by group as the HH size increased (69.6 ± 20.9, 83.5 ± 26.1, 99 ± 29.1, and 98.6 ± 24.9, respectively; p < 0.001). Eight of 35 patients with G-HH (22.9%) were treated urgently due to gastric incarceration. Postoperative complications were significantly more common after L-HH and G-HH repair (Figure 1). CD complications Grade II, IIIb, and IVa were observed only in patients with L-HH or G-HH. There was no mortality.
Conclusion
Patients with L-HH and G-HH are significantly older than those with S-HH or M-HH; this reflects the likely progressive nature of this pathology. Laparoscopic HH repair is associated with higher morbidity in patients with L-HH and G-HH. Furthermore, patients with G-HH are at risk of gastric incarceration, which requires emergency surgery. Our findings suggest that in patients with M-HH (even asymptomatic), a watch-and-wait strategy should be discouraged. Surgical repair, in experienced hands, is preferred.
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