PHH is not an uncommon entity. Surgeons in the twenty-first century encounter PHH in almost 50% of the cases during laparoscopic hiatal hernia repair [1]. PHH predisposes to gastroesophageal reflux disease (GERD) [11] and therefore the incidence of symptomatic cases of PHH is closely related to the diagnosis of GERD. Risk factors for developing PHH include body mass index (BMI) of >25, age > 50 and male sex. Increasing age is not only an independent risk factor for the development of GERD [12], but also increases the incidence of PHH. This is evident in a number of population based studies in various continents [13–16]. There is also a familial preponderance for developing PHH as it confers a 20-fold increased risk of developing PHH in younger siblings of children with this condition [17].

Patient selection and preoperative evaluation are crucial for successful PHH repair especially in elderly patients with multiple comorbidities. Larusson and his team [18] concluded that age, American Society of Anesthesiologists (ASA) score, and type of operation are significant predictive factors in patients undergoing laparoscopic PHH repair. The investigators advised caution in balancing surgical indications with each patient’s comorbidities, age, symptoms, and potentially life-threatening complications. Asymptomatic large PHH or those with minimal symptoms although uncommon, may be observed over a period of time, a strategy called ‘watchful waiting’ and only after these patients have been counselled regarding the risks of incarceration or strangulation which may require surgery in about 1.2% of the cases and carries mortality of 5.4% [19]. These patients, therefore, should be educated about the appropriate work-up in an elective situation in case emergency surgery is required in the future [20]. However, symptomatic PHH in reasonably fit patients should be offered an elective surgical option [21]. The most common symptoms include gastroesophageal reflux disease (GERD), non-cardiac chest pain, anemia, cardiac arrhythmias, aspiration and shortness of breath. Obstructive symptoms include early satiety, dysphagia and postprandial chest pain.

Preoperative evaluation for PHH repair requires four main studies which include (1) video esophagogram, a dynamic study which provides information about the overall size and position of the stomach within the hernia; (2) esophagogastroduodenoscopy which can provide information about the mucosa of the stomach and its associated conditions such as Cameron’s erosions, erosive esophagitis, and Barrett’s esophagus (Fig. 9.2). Additionally, it provides valuable information about Hill’s endoscopic classification of hernia (Fig. 9.3), level of esophagogastric junction, length of the esophagus and importantly to rule out malignancy; (3) high resolution impedance manometry (HRIM) proves valuable in planning the antireflux procedure which is part and parcel of hernia repair, whilst knowledge of motility patterns help plan the type of wrap created in these patients; and (4) lastly if GERD is a dominant symptom, 24 h ambulatory pH study will provide an objective score of GERD symptoms (Fig. 9.4). This baseline investigation can be quite useful should symptoms or problems develop in the future postoperatively. In addition to the above baseline foregut studies, depending on patients symptoms and co-morbidities, other investigations which may be of value in the preoperative period include nuclear medicine gastric emptying studies; chest and abdomen computerized tomography, pulmonary function tests, cardiac stress testing and echocardiogram in elderly patients with chest pain.

Many of the principles of standard fundoplication apply to PHH repair, the most important of which is the tension free repair of the crura [22]. The standard approach in the twenty-first century is laparoscopically via the abdomen although some great results achieved through a transthoracic approach in the twentieth century have to be acknowledged. In a study by Maziak et al. [23], 93% of the patients reported excellent results with a 10 year follow up with only 2 recurrences needing reoperation. However, this technique has fallen into disrepute because of the painful thoracotomy incision, insertion of chest tube, prolonged length of hospital stay and difficult reoperations in cases of complications or recurrence.

The four critical steps of the laparoscopic PHH operation include: (1) excision of the hernia sac in its entirety; (2) adequate mediastinal esophageal mobilization; (3) crural repair and (4) addition of fundoplication [24]. Incomplete dissection of the sac increases the risk of intrathoracic migration of the wrap and recurrence. Some studies have made use of this sac to provide cover to the mesh applied over the crura [7]. Similarly, incomplete mobilization of the esophagus to achieve adequate abdominal length of the esophagus (2–5 cm) or even the addition of Colles gastroplasty to achieve this maneuver in the case of a short esophagus is a vital step in preventing wrap migration and recurrence postoperatively [9]. The crural repair can be achieved either with sutures or a mesh. Cruroplasty is achieved with non-absorbable sutures, either in an interrupted or a continuous fashion (Fig. 9.5). Most of the sutures are placed posterior to the esophagus, although some may need to be placed anteriorly if the crura remains splayed after posterior cruroplasty [8, 25]. It is also common to reduce the intra-abdominal insufflation pressure while approximating the crura, especially for the large PHH. Some surgeons use mesh to reinforce the crural repair and the choice of mesh depends on personal preference of the surgeon and the size of the hiatal defect e.g., some choose to use mesh only when the hiatal defect is large or >5 cm [26, 27]. Mesh cruroplasty may significantly increase operating time (15–50 cm) as reported in a recent meta-analysis [28], but does not necessarily increase the rate of conversion to open [29]. It is standard to perform a fundoplication following crural closure. The type of fundoplication varies from complete to partial anterior or posterior fundoplication. Most common types are Nissen [30–32] (Fig. 9.6) and Toupet [33, 34]. Some surgeons in addition to fundoplication , suture the wrap to the crura or the stomach to the anterior abdominal wall or use tube gastrostomy to further prevent recurrence [7, 35]. The use of a bougie at the time of crural repair or while performing the wrap seems to be practiced by some surgeons [30, 31, 36]. However, it has fallen out of favor and is not considered as standard practice. This is because it possibly contributes to future recurrence by leaving a larger than required gap following cruroplasty [24].

An area of controversy is the use of prosthetic material (mesh) at the esophageal hiatus to provide additional support (Figs. 9.7 and 9.8). The majority of surgical mesh are constructed from synthetic materials or animal tissue. Synthetic mesh can be knitted or non-knitted sheet forms and can be absorbable, non-absorbable or a combination of these two. Animal-tissue mesh (bovine or porcine) are either made up of intestine or skin, and are absorbable. Non-absorbable mesh will remain in the body indefinitely and is considered a permanent implant. Absorbable mesh will degrade and lose strength over time. It is not intended to provide long-term reinforcement to the repair site. As the material degrades, new tissue growth is intended to provide strength to the repair. According to DeMeester [24] the characteristics of an ideal mesh for use at the hiatus include: (1) it should be absorbable with no tendency to erode; (2) easy to use in terms of introducing, positioning, and fixating; (3) provide long-term, effective strengthening of the crural closure and reduce the risk of a recurrent hernia, and (4) it should not preclude a safe reoperation if necessary.

In order to improve upon the high recurrence rate of suture cruroplasty, Carlson and his team, in 1999 [30], reported the very first randomized controlled trial (RCT) of laparoscopic prosthetic reinforcement of large hiatal hernia. Since then, many comparative trials [7–9, 25–27, 31–33, 36–41] and meta-analyses and systematic reviews [28, 42, 43] comparing suture cruroplasty versus mesh repair of large PHH have been published, analyzing various aspects of these two approaches (Table 9.1). Amongst the RCTs, two studies have made use of non-absorbable PTFE meshes [30, 31] and one of prolene mesh [32], while two others have used absorbable (Surgisis^® Cook Ireland) meshes with varying results [9, 41]. Similarly, a diverse range of meshes have been used in various other prospective and retrospective studies (Table 9.1). These include vicryl [26], ultrapro [26] and acellular dermal matrix [40]. These meshes have been applied for crural closure in various configurations which include a keyhole or circular configuration [31, 34] where the mesh surrounds the abdominal part of the esophagus, while others have used the mesh in “U” [33, 36], square or rectangular arrangements [7, 39] over the crura posterior to the esophagus. Some have even used the mesh as a bridge when the crural pillars could not be opposed [36, 38]. Although the majority of the surgeons have used staples [27, 30, 36], and tacks [25] to secure the mesh, some have utilized sutures which includes Ethibond^® [26, 27, 34, 36, 39], polyster [30], prolene [7], silk [40] or polybutester (V-Loc™) for either cruroplasty or/and to secure the mesh. Lastly fibrin glue has also been increasingly used for mesh fixation to the crura in recent days [44].

The significant complications related to the use of mesh in hiatal hernia surgery, include mesh infection, mesh erosion [45, 46], adhesions and fibrosis, migration of the wrap into the thoracic cavity (recurrence) and fistulae making revisional surgery very challenging even in the hands of the most experienced surgeons. Mesh related complications have been reported to range from 1.3 to 20% [47]. However, a recent systematic review has contradicted such a high rate [43]. Furthermore, a recent meta-analysis confirms comparable low complication rates between suture and mesh cruroplasty in PHH repair [28]. Yet another systematic review has shown a very low complication rate of only 1.9% for the mesh group [42] dispelling the long held belief that mesh repair has a higher complication rate especially over a long period of time. Non-absorbable mesh related complications occur at an average of 17.3 months (range 1–120) postoperatively and includes dysphagia, heartburn, chest pain, weight loss, epigastric pain and fever from sepsis. Once again it is important to emphasize that these complications are rare [47] (Table 9.2).