Surgical Management of Persistent or New Symptoms After Hiatal Hernia Repair

Redo foregut surgery is challenging in today's clinical practice and is fraught with increased morbidity and reportedly a lower 'success' rate than the index procedure. Here, we present a protocol for a redo hiatal hernia repair via a minimally invasive approach.

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. These may include recurrent reflux, dysphagia, regurgitation, weight loss, or deteriorating quality of life. While nonoperative management can be pursued in some patients, reoperation may be the only option in select patients. A thorough preoperative workup, including a repeat esophagram, upper endoscopy, +/- chest computed tomography (CT) scan, manometry, pH probe, and/or gastric emptying study, is warranted to better understand the pathophysiology of the presenting symptoms. If a recurrent hernia, slipped, or migrated wrap is identified, surgery is considered. Pseudoachalasia must also be ruled out if obstructive symptoms are observed at the hiatus. Such an exhaustive workup is indeed necessary to ensure accurate diagnosis and optimal outcome. In addition, an understanding of the factors that may have led to the recurrence will increase the chances of a successful reoperation. Although a technically demanding procedure, redo hiatal hernia repair utilizing a minimally invasive approach is increasingly being employed with promising outcomes. Herein, the steps of a redo hiatal hernia repair via a minimally invasive approach will be outlined and detailed.

Redo foregut surgery is emerging as an important challenge in modern surgical practice. "Failure of hiatal hernia repair" may occur early or late in the postoperative period. A thorough workup to understand the underlying pathology and cause of recurrent symptoms (e.g., heartburn, reflux, dysphagia, or chest pain) is essential to appropriately address the clinical problem. Failure of hiatal hernia repair in the early postoperative period (hours to days) can be attributed to poor patient selection and/or technical error. A delayed failure may be due to a recurrence either secondary to a technical failure, enlargement of the hiatus over time (both presenting as reflux), or secondary to adhesions at the hiatus resulting in pseudoachalasia (resulting in dysphagia).

Multiple factors may contribute to recurrent hiatal hernia. When the esophagus is placed on tension during the initial dissection and the gastroesophageal junction is believed to be in the abdominal cavity, this can result in failure to recognize a shortened esophagus. One of the key dogmas of index hiatal hernia surgery is to ensure an adequate intra-abdominal esophageal length of a minimum of 3-4 cm prior to the creation of a fundoplication. Therefore, to avoid this, a good mediastinal dissection should have been performed at the index operation up to the inferior pulmonary veins or higher in order to achieve this intra-abdominal length. In the absence of an adequate mediastinal dissection, the tension on the esophagus would result in the migration of the wrap back into the chest. Similarly, due to inadequate mediastinal dissection, the wrap may slip distally on the esophagus due to tension, resulting in hernia recurrence. In such cases, an esophageal lengthening procedure must have been employed. Incomplete removal of the hernia sac may also result in recurrence due to the potential space present within the mediastinum, which makes the hernia recur in a conducive manner. Finally, inadequate closure of the crus and obesity with increasing body-mass index has also been attributed to hiatal hernia recurrence^1,2.

Despite good initial surgical results, it is estimated that 15%-20% of patients will have symptomatic recurrence. While a majority of the patients can be treated non-operatively, up to 5%-10% of patients may require surgical revision³. Redo operations are technically demanding and may be associated with a higher rate of morbidity⁴. There is now ample evidence supporting the safety and efficacy of a minimally invasive approach to reoperation; however, these can still pose a great challenge for even experienced surgeons^5,6,7. Surgical correction of a recurrent hiatal hernia involves complete reduction of the hernia sac and contents followed by a redo fundoplication with or without gastroplasty. However, there are other options, including a bariatric weight loss procedure if the patient is morbidly obese, Roux-en-Y esophagojejunostomy, or an esophagectomy/gastrectomy depending on the complexity of the recurrent pathology (not discussed here and beyond the scope of this paper). These surgical options must be considered before taking the patient to the operating room.

Because these operations are difficult with poor delineation of anatomy, novice surgeons are encouraged to scrub in and/or seek help and guidance from experienced surgeons in their own practice and seek advice from their mentors prior to embarking on such challenging cases to optimize surgical outcome and avoid getting into surgical dilemmas during the operation itself. Herein, we describe the surgical steps and key principles of redo hiatal hernia surgery.

The described protocol follows the guidelines of our institution's human research ethics committee.

1. Preoperative assessment of the patient presenting with recurrent symptoms

1. Begin with a thorough history and physical exam of the patient. Elucidate the symptoms prior to the first surgery and compare them with current symptoms to better understand the underlying pathology.
   1. Whenever possible, attempt to review preoperative workup prior to index surgery, including the upper endoscopy and manometry, as it provides detailed information about the original location of the lower esophageal sphincter (LES), evidence of any Barrett's, resting LES pressure, integrated relaxation pressure, as well as details about esophageal motility (distal latency) and peristalsis.
   2. Obtain and review prior operative notes, particularly if the prior operations were performed by a different surgeon. Pay particular attention to details such as removal of the hernia sac, preservation of the vagi nerves, location of the gastroesophageal junction during the operation, need for an esophageal lengthening procedure, use of a Bougie prior to a Nissen fundoplication (if performed), and use of mesh.
2. Perform preoperative studies prior to reoperation
   1. Perform a thorough preoperative evaluation, including a barium esophagram and endoscopy.
      NOTE: While the barium esophagram is useful in defining the anatomy, the endoscopy allows for detailed inspection of the mucosa, evaluation for strictures, biopsy of the esophagus and stomach to evaluate for Barrett's and H. pylori as potential causes of symptoms, assessment of esophageal length and location of Z-line, assessment of the integrity and/or location of the prior wrap.
   2. Perform additional studies, such as esophageal manometry, pH testing, CT imaging, and gastric emptying studies, selectively if the clinical picture is indicative of recurrent reflux, pseudoachalasia, esophageal dysmotility, or delayed gastric emptying.

2. Preoperative preparation

1. Instruct the patient to keep a liquid diet for at least 24 h prior to surgery, followed by nil per os (NPO) after midnight.
2. Provide the patient undergoing redo surgery prophylactic antibiotics and subcutaneous heparin prior to induction of general anesthesia.
3. Place the patient supine on the operating table with arms abducted. Place a footboard to allow for steep reverse-Trendelenburg positioning to permit maximum exposure of the hiatus.

3. Minimally invasive approach: Scope insertion

1. If a preoperative endoscopy was not performed by the operating surgeon, perform an endoscopy to assess the location of the gastroesophageal junction and evaluate the integrity of the prior wrap.
2. Place a camera port using either an Optiview or a Hassan technique.
   NOTE: It is recommended to minimize air insufflation during endoscopy to minimize bowel distension and avoid an inadvertent visceral injury. Another safer option (and one the authors recommend) is to place at least one trocar prior to endoscopic insufflation, followed by placement of additional trocars under direct visualization after upper endoscopy is complete. This is safer to do so in case of gaseous distension from endoscopy and thus avoid cancellation of the case.
3. Trocar placement: Place a total of 5 trocars- two in bilateral upper quadrants, two in bilateral paramedian space, and one at the umbilicus. Place an assistant port at the surgeon's discretion/preference in the left or right lower quadrant under visualization.

4. Adhesiolysis and exposure

1. Achieve adequate adhesiolysis around the liver bed and crus, ensuring that the lesser curvature of the stomach is dissected off the right crus. When dividing adhesions between the liver and a prior wrap, err on the side of the liver as opposed to causing injury to the stomach or esophagus.
2. Once all adhesions are divided, define the right crus by carefully dissecting the stomach, esophagus, and hernia sac away from the crural fascia. Preserve the peritoneum on both crus to maintain the integrity of crural closure, especially in redo procedures. Here, the robotic platform provides a superior advantage, allowing the surgeon to precisely dissect around the crus and mediastinum.
3. When possible, undo the prior wrap. Have a surgical plan for this part of the operation.
   1. If a Nissen is being converted to a Toupet, do not perform a complete circumferential dissection. Loosen the wrap by an anterior dissection; this is usually sufficient. However, if a patient is being operated for pseudoachalasia, slipped or migrated wrap, perform a circumferential dissection to re-construct the wrap and evaluate the crural defect as well as the esophageal length.
      NOTE: Injury to the lesser curvature of the stomach or the esophagus can occur during this step. If the anatomy is unclear, a simultaneous on-table endoscopy can help guide the surgeon.

5. Mediastinal dissection and reduction of the hernia

1. Dissect the mediastinum with extreme caution in any redo case.
   NOTE: High mediastinal dissection is often not possible due to the presence of dense adhesive bands that are often foreshortened and heavily vascularized.
   1. Place gentle traction on the stomach with laparoscopic or robotic instruments to facilitate the reduction of the wrap and hernia contents into the abdomen, especially in the case of a slipped or migrated wrap.
   2. Using a hemostatic energy device, dissect the hernia sac out of the mediastinum (if not done in the past) using an avascular plane. Perform the dissection circumferentially, albeit in a piecemeal fashion.
      NOTE: In recurrent paraesophageal hernias, the hernia sac may be densely adherent to the pleura, and entry into the pleural space may be inevitable. If this occurs and the patient becomes symptomatic, placement of a chest tube or pigtail catheter must be performed immediately.
2. Identify vagus nerves
   1. During the mediastinal dissection, identify the esophagus as well as the anterior and posterior vagi to avoid any injury. If the planes are too ill-defined, use an endoscope intermittently throughout the operation to aid in defining the anatomy.
3. Obtain 3-4 cm of intra-abdominal esophageal length.
   1. If adequate mediastinal dissection of the esophagus does not allow delivery of the entire stomach and distal esophagus into the abdomen, consider an esophageal lengthening procedure (see section 6 below) instead of continuing aggressive mediastinal dissection.
4. Expose the retroesophageal window.
   1. To complete the circumferential dissection of the hiatus and assess the crural defect, retract the esophagus upward and to the left lower abdomen to allow exposure of the plane posterior to the esophagus.
   2. With this exposure, carefully create a retroesophageal window and widen it bluntly to enter the left side of the esophagus. Place a Penrose in this window to aid with completing the circumferential dissection and subsequent retraction.

6. Assessment of esophageal length

1. Once the mediastinal dissection is complete and the gastroesophageal junction is defined, assess the intraabdominal esophageal length prior to proceeding. Aim for at least 3 cm of tension-free intraabdominal esophageal length.
2. Esophageal lengthening procedure
   1. If there is inadequate intraabdominal esophageal length, perform an esophageal lengthening procedure. Perform an intra-abdominal lengthening procedure using an endoscopic stapler device to tubularize the proximal stomach to allow for lengthening of the esophagus with a Bougie dilator in place to avoid narrowing of the neo-esophagus.
   2. Remove the wedge V-shaped fundus from the abdomen via one of the laparoscopic ports, then create the wrap on this neo-esophagus.

7. Hiatal repair

1. Next, close the hiatus. Evaluate and close the posterior and anterior crural defects primarily whenever possible with a non-absorbable suture (size 0). If the integrity of the crural repair is in question, employ pledgeted sutures or overlay biologic mesh to reinforce the repair. Consider anterior crural closure to avoid kinking of the esophagus.

8. Creation of fundus wrap

NOTE: A Toupet fundoplication (posterior 270-degree wrap) is preferred in redo surgeries over a Nissen fundoplication (360-degree wrap) to prevent further scarring with complete wraps and secondary pseudoachalasia.

1. Pass the gastric fundus from the patient's left side of the abdomen to the right through the retroesophageal window.
   1. Perform a shoeshine maneuver by grasping the fundus of the stomach on either side of the esophagus and sliding it back and forth, posterior to the gastroesophageal junction, to confirm the proper orientation of the fundoplication and division of all attachments prior to creating a wrap.
2. Suture the wrap.
   1. Perform a Toupet fundoplication with 6 simple interrupted 2-0 non-absorbable sutures. Place three sutures at 10 o'clock and three at 2 o'clock on the esophagus. Ensure each bite is full thickness on the stomach and partial thickness on the esophagus.
   2. Perform a cruropexy of the wrap to each crural limb to prevent the wrap from migrating back up into the mediastinum.
3. Perform a completion endoscopy to look for injuries and the final configuration of the wrap.

9. Postoperative care

1. Perform an upper contrast study the next day to ensure there are no missing inadvertent injuries prior to initiating any oral intake.
2. If no defect or extravasation is noted, advise the patient to start on a liquid diet and gradually advance to a soft diet and regular food over a period of days to 2 weeks.

10. Follow-up

1. Follow up with the patient in the near future to document resolution of symptoms and development of any new symptoms thereof.
2. Routinely maintain the patients on a proton-pump inhibitor (PPI) for 1 month after surgery for ulcer prophylaxis. However, if a patient has underlying Barrett's or another acid-related pathology, defer this management to the referring gastroenterologist to ensure that the Barrett's pathology is completely resolved prior to stopping the PPI.

Table 1 summarizes the most recent studies reporting outcomes of redo hiatal hernia repair^{2,8,9,10,11,12,13}. The most common reason for the failure of the initial operation is migration of the wrap in 44%-89% of cases. A majority of cases were performed with a minimally invasive approach. Across the studies reviewed, in addition to hiatal hernia repair, a redo Nissen fundoplication was the most common fundoplication performed in 40%-80% of cases. A Collis gastroplasty was required in 24%-87% of cases. Overall complications ranged from 3% to 45%. An esophageal leak was one of the most feared postoperative complications, and it was reported in 2%-7% of cases. Length of follow-up varied; however, recurrence rates ranged from 4.4% to 31%.

Table 1: Summary of studies reporting outcomes of redo hiatal hernia repair. Abbreviations: NA, not available; RNY, Roux-en-Y; MIS, minimally invasive surgery.

With the exponential growth of hiatal hernia repair in the last few decades, there has been a dramatic increase in the number of patients presenting with recurrent or persistent symptoms. Causes of failure of the index operation may be multifactorial, but are most commonly attributed to obesity and a shortened esophagus^1,2. A thorough preoperative evaluation and diagnostic workup are necessary to identify the etiology and tailor the surgical approach. Isolating the cause of the patient's recurrent symptoms and establishing whether the symptoms are from surgical failure or attributable to some other etiology can be challenging. Symptoms should be clearly elicited - in terms of recurrent reflux, regurgitation of undigested food, chest pain/spasms, or early satiety indicative of delayed gastric emptying. A thorough analysis may possibly uncover a previously missed motility disorder.

Repair of recurrent hiatal hernia may be performed via a minimally invasive approach. During reoperation for recurrent hiatal hernia, the most critical steps are complete reduction of the hernia sac and contents and confirmation of adequate intraabdominal esophageal length. The surgeon must use intraoperative endoscopy to confirm adequate location of the gastroesophageal junction. An esophageal lengthening procedure may be necessary to achieve adequate esophageal length in order to reduce the chances of recurrence. The authors prefer to perform a Toupet fundoplication in these cases. A complete wrap may result in further scarring and secondary pseudoachalasia; therefore, we recommend avoiding a complete wrap if possible; however, this is at the surgeon's discretion. Finally, closure of the hiatal defect is an important aspect of this operation. Primary tension-free closure is advocated. However, depending on the size of the defect, the cause of recurrence, and the patient's overall protoplasm, a mesh repair may be indicated to decrease the risk of recurrence¹⁴.

Redo hiatal surgery is not without its complications⁴ and can range from 30% to 40% overall. Re-operative hiatal repair, especially in the setting of a prior implanted mesh, is fraught with complications. Therefore, patients should be adequately counseled and expectations set preoperatively. Many of these patients may not have complete symptom resolution. In addition, the chances of a subsequent recurrence are much higher after a first recurrence (up to 30%); thus, patients must be counseled accordingly. Postoperatively, most patients generally recover well and have symptom resolution with excellent patient satisfaction.

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