Operative Steps Laparoscopic Hiatal Hernia Repair

1) Excision of the hernia sac: The contents of the hernia sac are first reduced into the abdominal cavity.

2) Mobilization of the esophagus: The esophagus should be mobilized so that at least 3cm of the distal esophagus lies in the abdomen. This is to avoid recurrence. Usually, this is able to be achieved with high mediastinal dissection.

3) Closure of the crura: The enlarged diaphragmatic hiatus is closed primarily with suture for a tension free repair. There have been no long term studies that have demonstrated the greater efficacy or lower recurrence rates with mesh repair although short terms trials have supported the use of mesh.  When mesh is used, it typically is used as an onlay over crura that have been closed primarily.  Debate also continues on the type of mesh to employ.

4) Fundoplication: Most studies describe a fundoplication as a routine step in paraesophageal hernia repairs; however, this is not necessarily routinely performed by all surgeons.