Description

Introduction Redo hiatal hernia surgery presents a unique set of challenges for surgeons due to the complexity of altered anatomy, the presence of scar tissue, and the potential for complications from previous surgical interventions. At WALS 2025, Dr. Tarun Mittal shared his extensive expertise on the subject, outlining the latest techniques and advancements that improve patient outcomes in revision hiatal hernia repair. Challenges in Redo Hiatal Hernia Surgery Patients who require revision hiatal hernia surgery often present with a range of issues, including: 1. Recurrent Hernia: Some patients experience a return of the hernia due to factors such as inadequate closure of the diaphragmatic defect, excessive intra-abdominal pressure, or weakened tissue. 2. Scar Tissue and Adhesions: Previous surgery leads to fibrosis and adhesions, making dissection more difficult and increasing the risk of inadvertent injury to the esophagus or surrounding structures. 3. Esophageal Shortening: Recurrent hiatal hernias can be associated with esophageal shortening, requiring lengthening procedures such as a Collis gastroplasty. 4. Altered Anatomy: Previous surgical techniques, such as fundoplication or mesh repair, may distort normal anatomical landmarks, complicating reoperation. 5. Higher Risk of Complications: The risk of esophageal injury, gastric perforation, or vagus nerve damage is significantly higher in redo procedures than in primary repairs. Surgical Techniques for Redo Hiatal Hernia Repair Dr. Tarun Mittal emphasized a systematic approach to revision surgery, highlighting the following techniques: 1. Preoperative Planning and Imaging: - High-resolution esophageal manometry and pH testing to assess esophageal function. - CT scans and barium swallow studies to evaluate the extent of recurrence and anatomical alterations. 2. Safe Dissection and Adhesiolysis: - Careful identification and separation of scar tissue from the esophagus and stomach. - Use of advanced energy devices to minimize thermal injury and bleeding. 3. Esophageal Lengthening Procedures: - If the esophagus is found to be foreshortened, a Collis gastroplasty is performed to ensure adequate intra-abdominal esophageal length. 4. Reconstruction of the Hiatus: - Adequate mobilization of the stomach and esophagus to prevent undue tension. - Posterior crural closure with non-absorbable sutures or mesh reinforcement in select cases. 5. Revision of Fundoplication: - If previous fundoplication is dysfunctional, it may be revised or converted into a different type (e.g., Nissen to Toupet or vice versa). 6. Use of Biologic Mesh: - In cases of large defects or weak crura, biologic mesh reinforcement is preferred to minimize recurrence risk while avoiding complications associated with synthetic mesh. Advances in Redo Hiatal Hernia Surgery Dr. Mittal highlighted recent advancements that are improving outcomes in redo hiatal hernia surgery: 1. Minimally Invasive and Robotic Techniques: - Laparoscopic and robotic-assisted surgery provide better visualization, precision, and reduced postoperative pain compared to open surgery. 2. Enhanced Recovery Protocols (ERAS): - Early ambulation, multimodal pain management, and optimized nutrition contribute to faster recovery and reduced hospital stays. 3. Improved Mesh Materials: - The development of absorbable and biologic meshes has reduced complications associated with permanent mesh implantation. 4. Intraoperative Fluoroscopy and Endoscopy: - Routine intraoperative imaging helps confirm correct anatomical restoration and assess fundoplication wrap integrity. Conclusion Redo hiatal hernia surgery remains a challenging but necessary intervention for patients with failed primary repairs. With advancements in surgical techniques, technology, and postoperative care, outcomes continue to improve. Dr. Tarun Mittal’s insights at WALS 2025 have provided a valuable roadmap for surgeons tackling these complex cases, emphasizing precision, safety, and innovation to enhance patient care.