Carrott et al. [39] suggested that symptoms associated with paraesophageal hernia are varied, and that truly asymptomatic patients are rare. In this single-center review of 270 consecutive patients undergoing surgical repair of paraesophageal hernia, Carrott et al. found that symptoms included heartburn (65%), early satiety (50%), chest pain (48%), dyspnea (48%), dysphagia (48%), and regurgitation (47%). Due to the difficulty in evaluating the esophageal motor function in some of these patients and the common preoperative complaint of dysphagia [2, 38, 39], some surgeons prefer to perform a partial fundoplication (Figs. 11.3 and 11.4), rather than a total fundoplication [23, 24]. In fact, a partial fundoplication might be associated with fewer functional problems—leading to persistent dysphagia postoperatively—than a total fundoplication in those patients who might have undiagnosed impaired esophageal motility [38]. However, there has been little objective evidence to support this trend, and one might argue that the overall durability of a partial fundoplication in the control of reflux might be less reliable than that of a total fundoplication [40–43]. Currently, there is a large agreement to perform a partial fundoplication (either posterior or anterior) in patients with impaired esophageal motility. Allaix et al. [44] suggested performing a total fundoplication as the procedure of choice, while reserving a partial fundoplication in cases of severe esophageal dismotility or during emergencies, when the patient presents with signs and symptoms of incarceration or strangulation. The rationale of this approach was that patients are frequently elderly, often they do not have preoperative esophageal manometry, and a partial fundoplication might also be an effective form of gastropexy. Conversely, Arafat et al. [30] routinely performed manometry in all patients, and in those with a challenging insertion, they placed the manometry catheter with the help of an endoscope. Arafat et al. suggested performing a partial fundoplication when manometry showed aperistalsis or severe dismotility, yet not objectively defined. Auyang et al. [45] suggested performing a partial fundoplication in patients with 90% or more failed peristaltic contractions. Cohn et al. shunned from a total fundoplication in all patients with aperistalsis and those with severe dysphagia with inability to pass the manometry catheter. DeMeester and other authors reported that a fundoplication should always be added to all HH repairs and the type of fundoplication should be selected on the basis of the patient’s esophageal motility [32–34].

In the studies by Ponsky and Stiven, of 142 patients undergoing HH repair with a partial fundoplication–141 partial posterior (270 Toupet) and 1 partial anterior (180 Dor, due to the anatomical difficulties in performing a posterior wrap)—at a mean follow-up of 17 months, no patient reported reflux symptoms, while 4 (3%) patients (1 in the Ponsky and 3 in the Stiven study) presented with postoperative dysphagia requiring endoscopic dilation [23, 24]. In two studies, by Mittal et al. [10] and Van Der Westhuizen et al. [10, 11] no fundoplication was performed in patients with impaired esophageal peristalsis, and in patients with normal motility, the type of fundoplication was chosen according to gastric anatomy and fundus compliance. Overall, on a combined number of 225 patients, 150 (66.5%) underwent total fundoplication, 18 (8%) partial posterior fundoplication, 1 (0.5%) partial anterior fundoplication, 4 (2%) a gastric bypass for obesity (BMI[ 40 kg/m² ), and 52 (23%) had no fundoplication. Postoperatively, at a mean follow-up of 29 months, 18 patients (12%) who underwent a total fundoplication presented with dysphagia, with 10 requiring endoscopic dilation. Eleven patients presented postoperatively with symptoms of reflux, seven after a total fundoplication (4.6%), and four after PEH repair alone (7.7%), yet no postoperative pH monitoring was performed [10, 11]. Interestingly, Dallemagne et al. and Leeder et al. routinely performed a preoperative manometry and stated that they considered a total fundoplication as the procedure choice in all patients, while they reserved a partial fundoplication only to those with little compliance of the gastric fundus [12, 26]. Overall, on a combined number of 118 patients (96 total fundoplication, 11 partial anterior, and 11 partial posterior), among patients with total fundoplication, three had postoperative dysphagia (3%); two required a conversion to a Toupet fundoplication and 1 improved after endoscopic dilation. Among these 118 patients, 21 (18%) had postoperative reflux symptoms. Gouvas et al. [21] divided the 16 patients with abnormal esophageal motility in two subgroups: one group of nine patients who received a total fundoplication, and another group of seven patients who received a partial posterior fundoplication. At 12 months of follow-up, they showed that four patients (44%) after a total fundoplication and two patients (29%) after a partial fundoplication presented with postoperative dysphagia. Conversely, four patients (57%) presented with reflux symptoms after a partial fundoplication, while one patient (11%) presented with GER symptoms after a total fundoplication. In addition, all 16 patients underwent postoperative esophageal pH monitoring and all of those with a partial fundoplication had an abnormal amount of reflux (mean DeMeester score of 33), while 4 out of 9 patients (44%) after a total fundoplication had an abnormal amount of reflux (mean DeMeester score of 39).

These data have shown that in the majority of surgeons prefer to add a fundoplication to all HH repairs, preferably a total fundoplication in patients with normal esophageal motility. Despite this widespread tailored approach, as of today there is no evidence in literature that a fundoplication is better than another in preventing reflux and avoiding dysphagia in patients undergoing hiatal hernia repair, and the small prospective/retrospective and non-comparative studies in the literature do not help in drawing definitive conclusions. Based on our experience, we strongly suggest performing esophageal testing, when possible, and adopt a tailored approach performing a total fundoplication only in patients with effective esophageal motility.