Innovative Surgical Techniques to Reduce Recurrence in Laparoscopic Radical Treatment of Giant Hiatal Hernia

Abstract Background In Japan, there is an increasing trend in the number of esophageal hiatal hernia (EHH) surgeries performed in elderly patients. EHH in the elderly patients are associated with surgical invasiveness and complications, but safe surgery can contribute to improving quality of life (QOL). We report on the safe surgical technique and treatment results for giant hiatal hernia. Methods The most important point to be careful of when suturing the esophageal hiatus is damage to the diaphragm leg. If the esophageal hiatus is large, reducing the pneumoperitoneum pressure as much as possible will reduce the tissue resistance during suturing, allowing suture closure without placing excessive tension on the diaphragm legs. If the esophageal hiatus is large, the pneumoperitoneum pressure should be kept as low as possible to reduce tissue resistance during suturing and prevent damage to the diaphragm legs. Surgery is usually performed with a high pneumo-abdominal pressure of 10 mmHg, but if suture closure of the esophageal hiatus is difficult, suturing is performed with a low pneumo-abdominal pressure of 6 mmHg. We underwent 103 cases of EHH surgery between 2012 and 2022. There were 73 cases (70.8%) of over 75 years old patients, and 71 cases (68.9%) of giant mixed type EHH. We compared the surgical outcomes in the early group up to 2018, in which surgery was performed with high pneumo-abdominal pressure during hiatal closure, and the latter group, from 2019 onwards, in which surgery was performed with low pneumo-abdominal pressure during hiatal closure. Results 67 cases in the early group: 23 cases with sliding type/44 cases with mixed type (65.6%), 36 cases in the latter group: 8 cases with sliding type/27 cases with mixed type (75.0%), the proportion of mixed type was higher in the late group. Mesh was used in 1 case in the early group and 0 cases in the latter group. The recurrence rate was 7 cases (10.4%) in the early group and 1 case (2.8%) in the late group, and although the proportion of mixed type cases was higher in the latter group, the recurrence rate was lower. Reoperation for recurrence was performed in 1 patient in the early group. In one case of recurrent surgery in the early group, the type of recurrence was that the muscle bundle of the diaphragm leg on one side was torn, the hiatus was dilated, and the transverse colon was invaginated into the mediastinum. From this experience, I reaffirmed the importance of reliably suturing the esophageal hiatus without damaging tissue in order to reduce recurrence of giant hiatal hernia surgery. Although there are differences in observation periods, in recent years, appropriate management of intraoperative pneumoperitoneum pressure has been able to reduce recurrence and complications, and it has also been possible to safely improve QOL in elderly patients. Conclusions In giant hiatal hernia surgery, appropriate control of intraoperative pneumoperitoneum pressure can reduce recurrence.