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http://dx.doi.org/10.35630/2199-885X/2022/12/1.13

Modern aspects of diagnosis

and surgical treatment of hiatal R eceived 26 October 2021;

hernias: Literature Review Received in revised form 25 November 2021;

Accepted 26 November 2021

Igor Sovpel1,2  , Roman Ishchenko3  , Introduction

Igor Sedakov1,2  , Oleg Sovpel1,2  , Hiatal hernia is a disease characterized by
Vyacheslav Mykhaylichenko4  , displacement through the esophageal orifice of the
Dmitry Parshin5   diaphragm into the thoracic cavity of the abdominal
esophagus, cardia, upper stomach, and sometimes
1
M. Gorky Donetsk National Medical University, Donetsk intestinal loops [1]. Hiatal hernia is a fairly common
2
G.V. Bondar Republican Cancer Center, Donetsk disease and can often be diagnosed during examina-
3
Federal Scientific Clinical Center FMBA, Moscow, Russia tions for a completely different pathology, since in
4
S.I. Georgievsky Medical Academy, Simferopol most cases it is absolutely asymptomatic. According
5
Astrakhan State Medical University, Astrakhan, Russia to various authors, the detectability of this pathology
among the adult population can reach 20–30% [2].
[email protected] However, the long-term existence of hiatal hernia and
the associated trouble of anatomical and functional re-
lationships in the cardioesophageal zone, as a rule, over
A b s t r a c t — Laparoscopic correction is the main
method of treating hiatal hernias. However, despite
time leads to the onset of clinical symptoms, primarily
more than thirty years of experience, many issues remain associated with the development of gastroesophageal
controversial and require compilation and standardization. reflux, sometimes dramatically worsening the qual-
The authors have analyzed the latest scientific studies and ity of life of the patient and requiring treatment. The
recommendations on the treatment of hiatal hernias with only method of treatment that allows to eliminate the
a high level of evidence, which is presented in the form
of a review with a comparison of their own experience
existing hiatal hernia complicated by gastroesophageal
in surgical treatment of 171 patients operated on for reflux disease (GERD), is surgical. The laparoscopic
hiatal hernias. The risk of transition of an asymptomatic method is currently the gold standard in the treatment
hiatal hernia to a clinically significant one is 1% per year, of hiatal hernia and GERD [3].
while observation, rather than active surgical tactics, However, despite the almost thirty years of expe-
is indicated. Only symptomatic hernias are subject to
surgical treatment. Surgical intervention should include the
rience with laparoscopic interventions, a number of
following mandatory steps: dissection of the esophageal- issues still remains relevant. Such as: whether to oper-
diaphragmatic ligament with excision of the hernial sac ate hiatal hernia and GERD or to treat conservatively,
while protecting the branches of the vagus nerve; dissection determining the optimal volume and technique of the
of both crura of diaphragm, transhiatal mobilization of the surgical aid, choosing the method of cruroraphia, the
esophagus in the mediastinum to achieve the length of its
intraabdominal segment of 2–3 cm; if a short esophagus
need to use a mesh or biological graft to close a hernial
is suspected, a mandatory step is to perform Collis defect or strengthen sutures during plastic surgery of a
gastroplasty; mobilization of the gastric fundus by dividing hiatal hernia, the need to complement plastic surgery
gastrointestinal ligament and short gastric arteries; creation of esophageal hiatus by fundoplication or gastropexy
of a fundoplication cuff on a calibration probe of at least [4]. The widespread introduction of laparoscopic tech-
30–36 Fr. The choice of the fundoplication and cruroraphia
methods did not significantly affect the long-term results of
niques and the emergence of a large number of surgical
treatment. Laparoscopic interventions are the most effective methods for correcting hiatal hernia have not led to
way to treat patients with hiatal hernias, due to their safety, the development of a unified approach to the diagnosis
low trauma, low complication rate and the possibility of and surgical treatment of patients with this pathology.
rapid rehabilitation of patients. The technique of surgical
intervention needs a clarified standardization.
M at e r i a l a n d M e t h o d s
K e y w o r ds — hiatal hernia; fundoplication; recurrence; The present study analyzes the latest published
surgical mesh; symptom assessment; treatment failure; studies and recommendations on the surgical treat-
laparoscopic correction; diagnosis. ment of hiatal hernia with a high level of evidence,
which is presented in the form of a review with a com-
parison of data from our own retrospective analysis in
surgical treatment of 171 patients operated for hiatal
56 | archiv euromedica | 2022 | vol. 12 | num . 1 | Surgery

hernias for the period 2009–2018. Indications for pathology [6].And yet, the results of studiesshowed
surgical treatment were: that despite the high cost, laparoscopic hernia plastic
— clinically, radiologically and endoscopically surgery with fundoplication had the best indicators
confirmed hiatal hernia; of quality of life, especially in the group of patients
— inefficiency of conservative therapy of gastro- refractory to antisecretory drugs. All of the above was
esophageal reflux during more than 3 months; the reason to make a note in the recommendations of
— the presence of clinically significant ex- the Association of Gastrointestinal and Endoscopic
traesophageal (cardiac or bronchopulmonary) mani- Surgeons of America (SAGES) that absolutely forbids
festations of hiatal hernia and associated GERD. to operate on patients with sliding (type I) hiatal
hernia in the absence of a gastroesophageal reflux
All patients were operated in the scope of laparo- manifestations [7]. For paraesophageal hernias, it was
scopic cruroraphia with fundoplication. There were 69 noted that when using observational tactics, despite
men (40.4%)and 102 women (59.6%). The age of the the low percentage of urgent operations (less than 2%),
patients ranged from 25 to 74 years, the average age the risk of transformation of an asymptomatic hernia
was 54.2± 6.1 years. Nissen fundoplication was used into a symptomatic one is up to 14% per year[8].
in 109 cases, Toupet fundoplication was used in 62 Therefore, surgical intervention in fully asymptomatic
patients. In 29 patients with a hernia defect size of 5 cm paraesophageal hernias can be considered individu-
and larger, suture cruroraphia was supplemented with ally, taking into account age, concomitant pathology,
alloplasty. the risk of surgery and the experience of the operating
Statistical analysis was carried out using the surgeon. All experts unanimously agree that surgical
R Studio program Version 1.2.1335© 2009–2019 treatment is indicated for all patients with sympto-
R Studio, Inc., GPL. Quantitative variables are pre- matic hiatal hernia[9].
sented in the form of mean and standard deviation, Surgical intervention for hiatal hernia includes
since they all had a normal distribution (Shapiro-Wilk the following mandatory steps: moving the contents
test). When comparing two independent groups of the hernia into the abdominal cavity, isolation and
with quantitative variables, the Student's T-test was excision of the hernial sac, mobilization of the lower
used. Nominal and ordinal variables are represented third of the esophagus in the mediastinum in order to
as percentages. To compare the nominal scales, the achieve a sufficient length of the esophagus, closure of
Pearson criterion was applied if no more than 20% of the esophageal hiatus defect, formation of a fundopli-
the expected frequencies were less than 5, otherwise cation cuff. The literature describes several variants of
the exact Fisher criterion was applied. cardioesophageal junction mobilization [10, 11].Some
surgeons prefer to start mobilization from the left crus
L i t e r at u r e R e v i e w of diaphragm, arguing that with large hernias, the right
The formation of approaches to the treatment gastric artery and vein may be located in the hernial
of patients suffering from hiatal hernia had several sac, which, in case of mobilization from the right
stages. Initially, most surgeons adhered to active crus, may be injured. However, we prefer to start the
surgical tactics when detecting hiatal hernia, justify- operation by dissecting the gastro-hepatic ligament
ing the need for surgical intervention by prevention and mobilizing the right crus of the diaphragm.When
ofsevere complications associated with ischemia in dissecting the gastro-hepatic ligament, in 10–15%,
the hernial sac. However, in 2002, the publication of an additional hepatic artery may be found, which,
the Stylopoulosstudy[5] showed that when choosing especially in overweight patients, may be quite large,
the tactics of monitoring patients with this pathology, and with a rapid dissection can cause massive bleeding.
the frequency of theneed for urgent intervention was Regardless of the diameter, this vessel must be coagu-
1.1%, and the quality of life was lower in the group lated and dissected; attempts to preserve the latter
of routinely operated hiatal hernias compared with will not allow adequate access to the gastroesophageal
the observation group.At the same time, a fairly large junction and will create technical difficulties at the
number of publications appeared in the literature on stage of formation of the fundoplication cuff.In no
repeated surgical interventions performed for com- case did the dissection of the accessory hepatic artery
plications after plastic surgery of hiatal hernia. The affect the course of the postoperative period. Next,
appearance and widespread use of drugs of the proton one of the tools captures the bottom of the hernial sac
pump inhibitor group allowed to improve the quality and performs traction towards the abdominal cavity.
of life of patients with hiatal hernia and gastroesopha- The peritoneum is dissected along the border of the
geal reflux as a leading symptom, also at some stage hernial sac along the edge of the esophageal hiatus and
reducing the number of surgical interventions for this then the incision is extended circularly, separating the
Surgery | archiv euromedica | 2022 | vol. 12 | num . 1 |
57

left crus of the diaphragm. After the mobilization of p=0.00001). In a meta-analysis by Sathasivamet al.[17]
the diaphragm crura, usually in a "blunt" way, a tunnel (2019), the results of treatment of 942 patients were
is formed behind the esophagus, into which Penrose analyzed (mesh plastic surgery — 517 patients, suture
drainage or a thin gauze cloth is inserted to carry out microplasty — 425 patients), where the advantage of
traction during further mobilization of the esophagus mesh implant plastic surgery was also noted (OR 0.48,
in the mediastinum.At the same time, during the mo- 95% CI:0.32–0.73, p<0.05). In all the above studies,
bilization of the left semicircle of the esophagus, trac- there was no significant difference in the frequency of
tion for drainage is carried out towards the right crus intraoperative and postoperative complications.
of the diaphragm and, accordingly, vice versa. During
the mobilization of the esophagus, the diaphragmatic Our Experience and Discussion
nerves should be identified and traced in order to We conducted a retrospective analysis of the
avoid their trauma [12, 13]. results of surgical treatment of 98 patients operated
A clear definition of the required length of for hiatal hernia, with a hernial defect size of 5 cm or
esophageal mobilization is not described in the larger for the period 2009–2016. Depending on the
literature, it is generally understood that mobilization method of plastic surgery of the esophageal orifice of
is carried out until the length of the intraabdominal the diaphragm, patients were divided into 2 com-
segment of the esophagus, devoid of tension, is at least parison groups. The first group included 69 patients
2–3 cm. In order to achieve the required length of the who had hernial defect plastic surgery performed by
esophagus, some authors cite the length of the esopha- suture method. The second group included patients
gus mobilized in the mediastinum from 5 to 10–12 who underwent plastic surgery of hiatal hernia using
cm, other authors consider it necessary to mobilize it a mesh allograft (29 patients). In the group of cru-
to the level of the lower pulmonary vein.The isolation roraphia with alloplasty, the crura of the diaphragm
of the esophagus in the mediastinum should be carried during stitching were strengthened from the side of
out as close as possible to its adventitious membrane; the abdominal cavity with a mesh graft, which was
in this case, the probability of the pleura oozing or in- located in a V-shape. Analysis of long-term results 5
jury during mobilization is minimal. Nevertheless, one years after the study showed no advantage of using a
of the most unpleasant intraoperative complications is mesh graft for plastic surgery of large hiatal hernias in
the dissection of the esophageal muscle membrane or comparison with standard suture plastic surgery both
its perforation at the stage of mobilization [14]. in terms of recurrence rate — 4(13.8%) vs. 14 (20.3%),
One of the main problems after laparoscopic hi- CI: 0.19–2.1, p=0.44, and in assessing the quality of
atal hernia surgery is the high frequency of recurrence life according to the GERD-HRQL questionnaire.
which ranges from 10% to 40%. In order to improve Therefore, taking into account the likelihood of com-
long-term results, some surgeons, by analogy with plications associated with alloplasty, in particular mesh
the plasty of hernias of the anterior abdominal wall, erosion into the esophagus and dysphagia, do not
suggested using mesh prostheses for the plasty of large allow us to recommend this method for routine use.
defects ofesophageal hiatus, especially in cases where Nevertheless, in the case of using the alloplasty tech-
the closure of the hiatal opening without tension has nique, we, like most authors, prefer lightweight com-
certain difficulties.The multitude of various materials posite prostheses, preferably with an adhesive coating
used for both synthetic and biological transplants and [18]. We do not recommend the circular arrangement
methods of their fixation make certain difficulties in of the mesh around the esophagus, as well as the use of
developing a universal protocol for surgical interven- a tension-free option, closing the esophageal orifice de-
tion. Almost all meta-analyses published to date note fect only by the mesh. In order to reduce the likelihood
the advantage of using mesh implants in comparison of complications associated with the implantation of a
with suture plasty. The largest in the last few years are mesh implant, the latter should be located only behind
Tam et al. [15] (2016) who analyzed 13 studies, 1194 the esophagus in the area of the stitched crura of the
patients: 673 with mesh plastic surgery and 521 with diaphragm. We did not note any cases when we bring
suture plastic surgery. The recurrence rate was 13% in the crura together and close esophageal orifice in our
the mesh plastic surgery group versus 24% in suture practice.
plastic surgery group (HR 0.51, 95%; CI 0.30–0.87; Despite the opinion of some authors who ques-
p=0.014). In a published study by Zhang et al.[16] tion the need for the formation of a fundoplication
(2017), where the results of treatment of 719 patients cuff, we consider this stage mandatory for plastic
using a mesh implant and 755 with primary suture surgery of hiatal hernia. Indeed, to date, there is no
surgery were analyzed, the recurrence rate was 2.6% convincing evidence in the literature in favor of the
vs. 9.4%, respectively (OR 0.23, 95% CI 0.14–0.39, need for the use of fundoplication in plastic surgery of
58 | archiv euromedica | 2022 | vol. 12 | num . 1 | Surgery

hiatal hernia. According to some authors, the very for- by Engsrom et al.[22], and therefore is not used in our
mation of the fundoplication cuff, especially when the routine practice.
latter is fixed to the wall of the esophagus and the crura The method competing in the frequency of use
of the diaphragm, creates an additional obstacle to the with the fundoplication technique is the Toupetmeth-
herniation of the stomach into the mediastinum.There od, in which the formed fundoplication cuff envelops
are practically no works in the literature assessing the the posterior semicircle of the esophagus by 270°,
influence of both the fundoplication cuff itself and the leaving its anterior wall free. One of the latest meta-
method of its formation on the frequency of relapse analyses published by XingDu et al. [23] and compar-
in the long-term period. Only some studies provide ing the effectiveness of both methods of fundoplica-
data in favor of reducing the incidence of pathologi- tion included 1201 patients (8 randomized trials),
cal reflux in patients with a formed fundoplication laparoscopic Nissen fundoplication was performed in
cuff. According to our data, 89% of patients with 625 patients, Toupet method — in 567 patients. The
symptomatic hiatal hernia have clinical or endoscopic study showed no differences between the methods in
manifestations of pathological gastroesophageal reflux terms of the duration of hospitalization, the frequency
of varying severity, which dictates the need to perform of postoperative complications, patient satisfaction
an antireflux procedure. with the operation, postoperative heartburn, regurgita-
The most commonly used antireflux procedure is tion, esophagitis. When performing Nissen fundopli-
Nissen fundoplication, which we also prefer to routine cation, a shorter operation time and a higher pressure
use. In its standard form, this technique involves wrap- of the lower esophageal sphincter were noted, and the
ping the gastric fundus around the esophagus by 360°, frequency of dysphagia, gas-bloat syndrome and the
while the formation of the cuff itself is carried out at frequency of reoperations was higher. However, in the
the expense of the anterior and posterior walls of the same study, when conducting a subgroup analysis, it
gastric fundus. To do this, the posterior wall of the was noted that the differences between the methods
previously mobilized gastric fundus is captured with for dysphagia and gas-bloat syndrome disappeared
a soft clamp from the side of the right crus through with an increase in the observation period in the study.
the retroesophageal canal, and pulled in the direction We conducted a retrospective analysis of the
of the right crus. The anterior and posterior walls are results of surgical treatment of 171 patients operated
sewn together in front of the esophagus with 3-4 sepa- on for hiatal hernia associated with GERD. Depend-
rate seams with a braided non-absorbable "Ethibond" ing on the method of fundoplication, patients are
thread 2–0 or 3–0 for up to 3 cm. In order to prevent divided into 2 groups. The first group consisted of
dysphagia, the fundoplication cuff should be formed 109 patients, where Nissen fundoplication was used.
on a thick gastric tube 30–36 Fr. To prevent the The second group consisted of 62 patients who had
formed cuff from slipping off, the anterior semicircle Toupetfundoplication.A comparative analysis of
of the esophagus should be caught in two seams.Some the results of the use of various antirefluxtechniques
authors consider it necessary to fix the upper edge of showed their equal effectiveness in the short and long
the fundoplication cuff, as a rule, to the right crus in its term. The choice of the fundoplication method did
upper part. Many surgeons use a variation of this oper- not affect the duration of surgery, the frequency of in-
ation described by Rohr S. et al.[19] in 1992 as Floppy tra- and postoperative complications; the proportion
Nissen or Nissen-Rosetti in the literature, in which of functional dysphagia was 24 (22%) vs. 8 (12.9%),
the fundoplication cuff is formed only at the expense p=0.14; the number of unsatisfactory results, in par-
of the anterior wall of the stomach without dissect- ticular, relapse, was 19 (17.4%) vs. 15 (24.2%), p=0.48,
ing the gastrosplenic ligament ligament. Initially, this and of dysphagia – 8 (7.3%) vs. 2 (3.2%), p=0.27.
technique assumed the formation of a fundoplication Of particular interest is the appearance of an
cuff for a length of 4 to 6 cm. Currently, a length of up increasing number of publications devoted to the ef-
to 2 cm is considered sufficient, which in the literature fectiveness of the use of partial anterior Dor fundopli-
has acquired the term Short Floppy Nissen. Despite cation (which consists in fixing the anterior wall of the
the results of the meta-analyses conducted by Khatri gastric fundus to the anterior semicircle of the esopha-
et al. [20] and Markar et al. [21], which did not reveal gus and the crura of the diaphragm) compared with
significant differences between the above methods in the widespread Nissen and Toupetfundoplications in
functional results, we are of the opinion that restric- the aspect of use in hiatal hernia plastic surgery.Broed-
tion of the mobility of the gastric fundus can cause the ers et al., in a meta-analysis of surgical treatment of 458
formation of a fundoplication cuff with tension and patients, showed the same reflux control with a lower
increase the risk of dysphagia or "gas-bloat" syndrome frequency of postoperative dysphagia when perform-
in the long term, which is shown in the meta-analysis ing anterior Dor fundoplication compared with Nis-
Surgery | archiv euromedica | 2022 | vol. 12 | num . 1 |
59

sen fundoplication [24]. A retrospective cohort study 2. Andolfi C., Jalilvand A., Plana A., Fisichella
that was conducted by Trepanier et al. showed that the P.M. S urgical Treatment of Paraesophageal Hernias: A
use of Dor and Nissen fundoplications is equivalent Review.Journal of Laparoendoscopic& Advanced Sur-
gical Techniques 2016;26(10):778–783.doi:10.1089/
in the effectiveness of reflux control in the plastics of lap.2016.0332
large paraesophageal hernias [25].
The frequency of occurrence of a short esopha- 3. Kohn G.P., Price R.R., DeMeester S.R., Ze-
hetner J. G uidelines for the management of hiatal
gus according to the literature varies from 0 to 60%, hernia. Surgical endoscopy. 2013;27(12):4409–4428.
averaging from 5% to 20%. Thus, Madan et al. [26], doi:10.1007/s00464-013-3173-3/
citing the experience of 628 patients operated on in the
4. Bujoreanu I., Abrar D., Lampridis S., Date R.
scope of fundoplication, of which 351 patients were Do Poor Functional Outcomes and Higher Morbidity
operated on for hiatal hernia, noted the absence of the Following Emergency Repair of Giant Hiatus Hernia
need for esophageal elongation procedures. Nason et Warrant Elective Surgery in Asymptomatic Patients?
al. [[27,28,29], citing the results of surgical treatment Front. Surg. 8:628477. doi: 10.3389/fsurg.2021.628477
of 795 hiatal hernias, performed Collis gastroplasty in 5. Stylopoulos N., Gazelle G.S., Rattner D.W.
454 (57%) patients. Paraesophageal hernias: operation or observation?
Early destruction of the fundoplication cuff or Ann Surg. 2002;236:492–500. doi:10.1097/00000658-
the eruption of sutures on the crura of the diaphragm 200210000-00012
with the development of early recurrence of hiatal 6. Siegal S.R., Dolan J.P., Hunter J.G. M  odern
hernia is extremely rare and, as a rule, is due to a sharp diagnosis and treatment of hiatal hernias. Langenbecks
increase in intra-abdominal pressure caused by vomit- Arch Surg. 2017;402:1145–1151 doi:10.1007/s00423-
017-1606-5
ing or coughing during the patient's recovery from
anesthesia. To prevent these complications, massive 7. Rickenbacher N, Kötter T, Kochen MM,
antibiotic therapy should be carried out.Ifthe patient Scherer M, Blozik E. Fundoplication versus medi-
cal management of gastroesophageal reflux disease:
has concomitant pulmonary pathology, the cough systematic review and meta-analysis. Surg Endosc.
reflex should also be suppressed.Given the probability 2014 Jan;28(1):143–55. doi: 10.1007/s00464-013-
of developing postoperative dysphagia of a functional 3140-z
nature, which according to our data and literature data 8. Lebenthal A., Waterford S.D., Fisichella
can reach 20–30%, it is generally accepted to gradu- P.M. T reatment and controversies in paraesophageal
ally switch from liquid to solid food within 4-6 weeks. hernia repair. Front Surg. 2015;2(13). doi:10.3389/
Many authors do not recommend performing routine fsurg.2015.00013
radiopaque examinations for patients who do not have 9. Ugliono E, Rebecchi F, Seno E, Morino M.
any clinical manifestations. We are of the opinion that Large hiatal hernia: minimizing early and long-term
such a survey is necessary at least once a year. complications after minimally invasive repair. Mini-in-
vasive Surg 2021;5:2. doi:10.20517/2574-1225.2020.93
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Laparoscopic interventions are the most effective repair of paraesophageal hiatal hernias. J Laparoendosc
Surg. 1993;3:331–338.doi:10.1089/lps.1993.3.331
way to treat patients with hiatal hernia complicated by
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tion rate and the possibility of rapid rehabilitation of scopic repair of giant hiatal hernia for elderly patients.
Ann Transl Med. 2021;9(8):704. doi:10.21037/atm-
patients. Prevention and reduction of the frequency 21-1495
of complications is possible with the surgeon’s clear
understanding and knowledge of the subtleties of 12. Dallemagne B., Kohnen L., Perretta S.,
Weerts J., Markiewicz S., Jehaes C. L  aparo-
the surgical intervention. Further generalization and scopic repair of paraesophageal hernia. Long-term
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