Laparoscopic Hiatal Hernia Repair in Over 65-Year-Old Population: Feasibility, Technique, and Early Results

Background: The incidence of hiatal hernia (HH) and associated comorbidities increases with age, which contributes to a higher perioperative risk in elderly patients. As life expectancy rises, general surgery must increasingly confront the challenge of treating this benign yet symptomatic condition in the elderly, where the primary goal is functional improvement and enhanced quality of life. We aimed to evaluate the safety and efficacy of laparoscopy for HH repair in this high-risk patient cohort. Methods: In a prospective database, we enrolled all consecutive elderly (65-year-old or older) patients who underwent laparoscopic HH repair (hernia reduction, cruroplasty, and fundoplication). Data analyzed included demographic and anthropometric, intra-operative and post-operative results and complications, mortality, length of stay (LOS), and clinical results during follow-up. Results: We enrolled a total of 28 patients, of whom 8 were males (28.6%), and 20 were females (71.4%). All patients came to consultation because of strong symptoms and were studied with esophagogastroduodenoscopy, x-ray oral swallow/oral contrast CT-scan, 24-hour pH-Impedance testing, and high-resolution esophageal manometry. Median age at the time of surgery was 73 (IQR 68-77) years, mean body mass index (BMI) was 24.5±2.3 Kg/m 2, and median Charlson Comorbidity Index was 3.5 (IQR 3-4.75), corresponding to an estimated mean 10-year survival of 57.7%. Intraoperatively, a total of 3 complications (10.7%) were observed (2 cases of pneumothorax requiring placement of a chest drain, and 1 case of gastric perforation managed with laparoscopic suture); mean operative time was 162±79 minutes, and mean intraoperative blood loss was 42.5 mL (range: 0 to 200). A total of 14 Toupet fundoplications (50%) and 14 Nissen fundoplications (50%) were performed. A mesh was positioned in 1 patient (3.6%). No conversions to open surgery occurred. Post-operatively: three patients (10.7%) were transferred to the intensive care unit for monitoring; 4 complications occurred (14.3%): 3 radiologic pneumothoraxes (Clavien-Dindo score 1) and 1 cruroplasty disruption following extubation (Clavien-Dindo score 3). The mean LOS was 4.3±1.4 days. Peri-operative mortality was 0%, and there was one 90-day readmission (3.6%). During a mean follow-up period of 20±15 months, no HH recurrences or wrap stenosis were observed. Conclusions: Despite the ongoing debate regarding upper gastrointestinal minimally invasive surgery in elderly patients with multiple comorbidities, this study shows that a laparoscopic approach for symptomatic HH in an elderly population is feasible and safe, with no severe complications and no mortality, with favorable outcomes during follow-up. Advanced age alone should not be a limiting factor for the surgical decision-making, especially in experienced centers.