Hiatal Hernia Repair Without Fundoplication - Houston Heartburn and Reflux Center (2024)

I read with great interest the recent study “Fundoplication at the time of paraesophageal hernia repair does not decrease the rate of hernia recurrence or postoperative reflux” published in Surgical Endoscopy Journal. The authors retrospectively examined the outcome of 1155 patients who underwent paraesophageal hernia, PEH, repair at a single institution from 2010 till 2023. 53% of patients underwent paraesophageal hernia repair with concomitant Nissen fundoplication. the remaining patients had a paraesophageal hernia repair only. The authors found no difference in the rate of reoperation and postoperative GERD between both groups. The fundoplication group had a higher rate of dysphagia. The study concludes: “While there are definite indications for fundoplication at the time of PEH repair (i.e., type 1 hernia), these data do not support the routine use of fundoplication during PEH repair with a normal gastroesophageal flap valve intraoperatively”.

These findings underscore an important perspective on the management of hiatal hernia and the role of Nissen fundoplication, particularly in the context of different types of hiatal hernias and their relationship to gastroesophageal reflux disease (GERD).

Nissen fundoplication is the most reliable solution for GERD. However, not all hiatal hernias are associated with GERD. Indeed, paraesophageal or hiatal hernias are anatomically classified into 4 types depending on the location of the lower esophageal sphincter relatively to gastric fundus and hiatal opening. Only type 1 hiatal hernia also known as sliding hiatal hernia is strongly associated with GERD. Type 1 hiatal hernia repair by itself does not restore the antireflux barrier. Therefore, adding a Nissen fundoplication is crucial in this type of hiatal hernia to stop GERD. On the other hand, type 2, 3 and 4 PEH are typically not associated with GERD. Hence, the addition of a fundoplication in this case, which is common practice, is unnecessary. I agree with the authors’ conclusions.

Instead of a fundoplication, anchoring the stomach in the abdomen may help reduce the hiatal hernia recurrence rate which, for type 2,3 and 4 PEH, approaches 50% at 5 years. After all, the primary concern for type 2,3 and 4 hiatal hernias is the risk of gastric volvulus (stomach twisting on itself in the chest), and strangulation (loss of blood supply). From this perspective, an anchoring procedure like the Hill repair seems to be a better alternative than a Nissen fundoplication. A modified version of the Hill repair, (since there is no need to reconstruct the angle of His for acid reflux control), can be adopted to fixate the posterior aspect of the gastroesophageal junction to the pre-aortic fascia. Adding a gastric tube may help vent the stomach in the postoperative period as well as anchor the anterior stomach wall.

In conclusion, this study reinforces the tailored approach needed in hiatal hernia repair surgery, where the choice of procedure depends largely on the type of hiatal hernia, associated symptoms, and the specific pathology involved. The pathophysiology of type 1 PEH is closely linked to GERD, and it is dramatically different from that of type 2,3 and 4 PEHs. At Houston Heartburn and Reflux Center, we mainly treat type 1 or sliding hiatal hernias for GERD management. Our Nissen fundoplication dysphagia rate is zero and our long-term recurrence rate is less than 1%. We believe that GERD causes a sliding hiatal hernia to develop, and a sliding hiatal hernia exacerbates GERD. For this reason, hiatal hernia by itself is not enough for GERD control. To restore the antireflux barrier, a Nissen fundoplication must always be added for type 1 PEH repair.