Bankstown Hospital - Grand Rounds - Further Reading

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Hiatus hernia

Akmaz, B., et al. (2025). "Patient Factors Influencing Surgical Technique in Hiatal Hernia Repair: In Search for Surgeons’ Hidden Algorithm." Digestive Surgery:   https://doi.org/10.1159/000545340 REQUEST ARTICLE FROM LIBRARY

Introduction: Laparoscopic fundoplication is the current standard for HH repair. HH repair can be reinforced with additional anterior sutures, vertical mesh strips (VMS), or mesh placement. We analyzed the influence of patient factors on the surgical technique for laparoscopic repair in a teaching hospital. Methods: Between 2012 and 2019, all patients who underwent repair of HH were assessed in this retrospective cohort study. HH was measured on CT scans and baseline patient characteristics and surgical details were collected. Results: In total, 307 patients were included. A total of 208 patients underwent a Toupet fundoplication and 97 patients underwent a Nissen fundoplication. Reinforcements consisted of anterior sutures in 132 patients, VMS in 89 patients, and mesh in 17 patients. The use of anterior sutures was significantly associated with female gender, higher type of HH, and higher age. The use of VMS during surgery was significantly associated with higher type of HH, higher age, and larger transverse diameter of the HH. The use of mesh during surgery was significantly associated with higher type of HH and larger transverse diameter of the HH. Conclusion: In this retrospective study, the reinforcement techniques used during surgery were significantly associated with patient factors such as gender, body length and weight, type of HH, and transverse diameter. An unexpected patient-associated factor was age.

Amprayil, M. A., et al. (2025). "Safety and Early Clinical Outcomes Following Repair of Very Large Hiatus Hernia in Octogenarians." World Journal of Surgery 49(5): 1237-1245  https://onlinelibrary.wiley.com/doi/abs/10.1002/wjs.12569  PDF AT LINK

  ABSTRACT Background Very large hiatus hernias are often symptomatic, impact quality of life, and are increasingly encountered in aging populations. Laparoscopic repair offers excellent clinical outcomes. However, surgeons can be reluctant to offer surgery to the elderly due to concerns about morbidity and mortality. To determine safety, we evaluated outcomes following repair of very large hiatus hernias in patients aged 80 years and older and compared them to younger patients. Methods Data were extracted from a prospective database. Patients who underwent operative repair of a very large hiatus hernia (> 50% intrathoracic stomach) between 2000 and 2023 were included and categorized into groups based on age: young (< 70 years), older (70–79 years), and octogenarian (≥ 80 years). Perioperative and early postoperative clinical outcomes were determined and compared. Results 1353 patients underwent surgery (< 70 years: 733 [54.2%], 70–79 years: 451 [33.3%], and ≥ 80 years: 169 [12.5%]). Rates of total intrathoracic stomach were commonest in octogenarians (11.6% vs. 20.4% vs. 32.5% and p < 0.001). Young and older patients were more likely to undergo elective surgery for heartburn (56.6% vs. 44.4% vs. 29.0% and p < 0.001), whereas octogenarians more likely underwent emergency surgery for gastric volvulus (5.4% vs. 6.6% vs. 14.5% and p = 0.019). Conversion to open surgery (1.1% vs. 1.1% vs. 5.0% and p = 0.002) and length of stay (2.69 vs. 3.19 vs. 4.62 days and p < 0.001) were greater in the octogenarian group. Major complications (4.2% vs. 5.1% vs. 8.1% and p = 0.120) and return to theater rates (2.6% vs. 2.9% vs. 2.7% and p = 0.925) were similar. Thirty-day mortality rates were low for all groups but highest in octogenarians (0.3% vs. 0.4% vs. 1.8% and p = 0.048). Adverse outcomes were more likely with emergency presentations, which were more common in octogenarians. Conclusion Despite a higher rate of emergency surgery in octogenarians—major complications and overall mortality rates are still acceptably low. Repair of very large symptomatic hiatus hernia should not be withheld from patients aged over 80 who are otherwise fit.

Garsot, E., et al. (2025). "Robotic hiatus hernia surgery: learning curve and lessons learned." Journal of Robotic Surgery 19(1): 51  https://doi.org/10.1007/s11701-024-02191-3  PDF AT LINK 

New procedures like the robotic approach require proficiency to ensure patient safety and satisfactory functional results. Hiatal hernia surgery serves as a suitable training procedure for upper gastrointestinal tract surgeons transitioning to the robotic approach. This study aims to evaluate the outcomes of implementing the robotic approach in hiatal hernia surgery at a tertiary hospital and to assess the associated learning curve. A retrospective review was conducted on 54 patients (58 surgeries) between June 2019 and March 2024, including both primary and revision robotic antireflux surgeries. The study focused on perioperative outcomes, symptom resolution, and the surgical learning curve, assessed using Cumulative Sum analysis. The results showed that global surgical time averaged 124 ± 57 (54–350) min, 127 ± 38 (116–139) for Primary Surgery and 164 ± 84 (115–212) min for Revisional Surgery. There were no conversions to laparoscopic or open approach. The global median of hospital stay was 2 days (2 for Primary Surgery and 3 for Revisional Surgery) and three patients required readmission (2 for Primary Surgery and 1 for Revisional Surgery). Postoperative complications occurred in 3 patients. Symptom resolution was achieved in 90% of Primary Surgery group and 85.7% of Revisional Surgery group. Learning curve described three phases: 1-training (case 1 to 14), 2-plateau (15 to 25) and 3-expertise phase (25 onwards). The robotic approach in hiatal hernia surgery is feasible with minimal morbidity, short hospital stays, and excellent functional results. With previous experience in laparoscopic approach and esophagogastric surgery the learning curve can be reduced to 14 procedures.

Liu, D. S., et al. (2024). "Quantifying Perioperative Risks for Antireflux and Hiatus Hernia Surgery: A Multicenter Cohort Study of 4301 Patients." Annals of Surgery 279(5): 796-807  https://journals.lww.com/annalsofsurgery/fulltext/2024/05000/quantifying_perioperative_risks_for_antireflux_and.11.aspx   PDF AT LINK 

Objective: Using a comprehensive Australian cohort, we quantified the incidence and determined the independent predictors of intraoperative and postoperative complications associated with antireflux and hiatus hernia surgeries. In addition, we performed an in-depth analysis to understand the complication profiles associated with each independent risk factor. Background: Predicting perioperative risks for fundoplication and hiatus hernia repair will inform treatment decision-making, hospital resource allocation, and benchmarking. However, available risk calculators do not account for hernia anatomy or technical aspects of surgery in estimating perioperative risk. Methods: Retrospective analysis of all elective antireflux and hiatus hernia surgeries in 36 Australian hospitals over 10 years. Hierarchical multivariate logistic regression analyses were performed to determine the independent predictors of intraoperative and postoperative complications accounting for patient, surgical, anatomic, and perioperative factors. Results: A total of 4301 surgeries were analyzed. Of these, 1569 (36.5%) were large/giant hernias and 292 (6.8%) were revisional procedures. The incidence rates of intraoperative and postoperative complications were 12.6% and 13.3%, respectively. The Charlson Comorbidity Index, hernia size, revisional surgery, and baseline anticoagulant usage independently predicted both intraoperative and postoperative complications. These risk factors were associated with their own complication profiles. Finally, using risk matrices, we visualized the cumulative impact of these 4 risk factors on the development of intraoperative, overall postoperative, and major postoperative complications. Conclusions: This study has improved our understanding of perioperative morbidity associated with antireflux and hiatus hernia surgery. Our findings group patients along a spectrum of perioperative risks that inform care at an individual and institutional level.

Smith, B. A., et al. (2025). "Robotic surgery for giant paraesophageal hernias: a promising approach to improved outcomes." Journal of Robotic Surgery 19(1): 83  https://doi.org/10.1007/s11701-025-02247-y  REQUEST ARTICLE FROM LIBRARY

 Giant paraesophageal hernias (GPEH) present challenges in management and surgical technique. Laparoscopic repair has been the gold standard for GPEH repair. Despite technical advances in laparoscopy, complications and recurrence remain high. The da Vinci Surgical System has emerged as a way to improve upon the gold standard. The objective of this study is to evaluate clinical outcomes of patients who underwent robotic GPEH repair in comparison to the clinical data in the literature on laparoscopic GPEH repair. We retrospectively reviewed patient records who underwent GPEH repair between November 2012 and February 2023 at a single high-volume tertiary care center. Perioperative data and patient outcomes were collected from a prospectively maintained database. Ninety-two patients underwent robotic GPEH repair. Sixty-seven had Type III hernias (72.8%) and twenty-five had Type IV hernias (27.2%). Four (4.3%) required conversion to open repair and two (2.2%) required reoperation for recurrence. Twelve (13.0%) experienced complications including one surgical complication (splenic laceration) and eleven medical complications (fever, ileus, pleural effusion, and heart failure exacerbation). There was no perioperative mortality. Mean operative time was 166.4 ± 29.5 min, and hospital stay was 5.8 ± 3.1 days. Obesity (BMI > 30) was associated with higher complication and recurrence rates. Robotic GPEH repair demonstrates promising outcomes, with lower recurrence rates and fewer postoperative complications compared to published data on laparoscopic repair. While a randomized control trial is needed to substantiate these results, our data support that a robotic approach could become the standard of care for GPEH repair.