Revisional Hiatal Hernia Surgery

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Definition- Elective/Urgent/Emergency revisional surgery to correct a recurrent primary symptom * +/- associated secondary symptoms ** with evidence of a recurrent hiatus hernia (>1/3 of stomach in chest or GOJ >5 cm from hiatus),excludes acute complications of primary procedure

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* Primary Symptom

Episode of emergency volvulus/post-prandial chest pain/shortness of breath/nausea and weight loss/dysphagia and weight loss /iron deficiency anemia (other causes excluded)/major respiratory aspiration event

** Secondary Symptom

Reflux/dyspepsia/post-prandial chest pain/shortness of breath/nausea/dysphagia/weight loss/iron deficiency anemia (other causes excluded)/minor aspiration respiratory events

 

Classification of Recurrence

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Recurrent Type III (Large)

Displacement of GOJ >5cm above diaphragmatic hiatus or >1/3 of stomach volume within chest on CT/contrast study     

                          

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Recurrent Type III Intra-Thoracic Stomach  

Pylorus at, or above level of diaphragmatic hiatus, or if within the abdomen < 5cm distance from diaphragmatic hiatus 

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Recurrent Type IV

Another organ above the level of the diaphragmatic hiatus, small/large bowel, pancreas, spleen (not inclusive of omentum)    

 

 

 

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Recurrent Type II (Large)

>1/3 of stomach volume above level of the hiatus with the GOJ remaining at or below level of diaphragmatic hiatus (RARE)             

 

Revisional surgery has more complex management and should be concentrated to a few surgeons within a large unit or a single centre within a region

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It is recommended patients should have pre-operative OGD and cross-sectional imaging for surgical planning and exclusion of synchronous pathology

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Strong consideration should be given to gastropexy/gastroplasty in these cases

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Pass patients through a hiatal MDT* prior to surgery, best practice to discuss all elective patients prior to surgery

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Enter data into a registry to audit outcomes