There is a paucity of data on the predictors of hernia recurrence following laparoscopic repair of hiatus hernia despite recurrence rates having been extensively evaluated 6,7, 11, 12, 19,20,21,22,23. Data on the prediction and potential prevention of hernia recurrence after repair is important for the ongoing refinement of this operation to improve durability of repair. Small numbers of reports have suggested that obesity, hernia size and type, technical issues including suturing under tension, inadequate esophageal mobilizsation, and tension, as well as postoperative retching and vomiting, were risk factors for recurrence 11,12, 21. Some of these factors were similarly found to contribute to recurrence in this study. These included age < 70 years, presence of Barrett’s esophagus, and hiatus closure under tension. Absence of “composite repair” was also a significant predictor of recurrence and unique to this study.

It has been established that laparoscopic repair yields high rates of symptom resolution and improved QOL 11,24. When evaluated objectively with imaging, however, there can be high rates of anatomical recurrence of up to 66% 8. There is evidence that the high prevalence of anatomical recurrence following repair does not directly correlate with symptomatic recurrence 4,5,6. The anatomical recurrence rate in this study (27.4%) is fairly low considering the liberal definition of recurrence used. Less than half of the patients with anatomical recurrence in this series were symptomatic, and less than a third of those with symptoms required revision surgery, consistent with the low rates described in the literature 22,25,26,27. Recurrent hernia of < 2cm or > 2cm in size were also found to be similarly associated with recurrent symptoms in this series, suggesting that patients can be symptomatic even from small recurrences. These findings indicate room for potential improvement in the durability of laparoscopic repair of giant PEH when using anatomical recurrence as a measure for durability of repair.

Factors associated with recurrence, particularly for giant PEH, have yet to be fully defined. Risk factors for recurrence following repair would theoretically be those that stress the diaphragm, increase the abdominal to thoracic cavity pressure gradient, or make it difficult for hiatus tissue to resist forces applied to it 28. Age less than 70 years was associated with higher risk of recurrence in this study. Age was not a significant predictor of recurrence after laparoscopic repair of large type III hiatus hernia and giant PEH in other studies 12,13, 25, 26. Recurrence may not be solely related to patient age, but it is possible younger patients are more likely to have increased activity level and potential of higher generation of intra-abdominal pressure so stressing the repair. Similar to previous studies, BMI and ASA grade were not found to significantly influence rates of recurrence in this study 13. A deficiency in understanding the effect of BMI in this study is the recording of weight after significant preoperative instructed weight loss. Perhaps weight at initial presentation may have been predictive, as could postoperative weight gain but this data was not prospectively stored.

Presence of Barrett’s esophagus preoperative was identified to be an independent factor associated with hernia recurrence. Patients with severe esophagitis or Barrett’s esophagus have been demonstrated to have a significantly higher prevalence of larger hiatus hernia than patients with non-erosive reflux disease or mild esophagitis 29. Higher recurrence rates following anti-reflux surgery have been shown to occur in Barrett’s esophagus compared to uncomplicated gastro-esophageal disease 30. This could reflect lack of pliability in the esophagus secondary to more severe and prolonged acid exposure.

The hernia type and size in this study did not significantly influence recurrence rates, similar to previous studies 13. Hernia size as a predictor of recurrence has had conflicting results in studies evaluating repair of hiatus hernia of any size. Larger hernia size (> 5cm) was a significant predictor of recurrence in some studies 25,27, 31 and not significant in others 13,26. Studies reporting a centimetre measure are largely reporting the elevation of the lower esophageal sphincter above the crural diaphragm, not true hernia size (amount of stomach volume in the mediastinum) and could be misleading.

Given that few patient or hernia related factors have been shown to be associated with recurrence, the more pertinent factors associated with recurrence could arguably be operative factors. This provides room for improvement of technical aspects of the operation for better outcomes. The generally agreed upon essential technical aspects of hiatus hernia repair include sac removal from mediastinum, esophageal mediastinal mobilization to allow a tension free intra-abdominal esophageal length, avoidance of sutures under too much tension at the crural closure, and fundoplication for the anti-reflux barrier 17,23, 32. A non-mesh approach yielded reasonable results in this series. Crural repair augmentation by mesh hernioplasty is controversial and not yet definitively proven to be superior to sutured hiatal closure 17. Recent meta-analyses have demonstrated that both techniques deliver comparable outcomes 19,33,34,35,36.

Collis gastroplasty used to be an aspect of anti-reflux surgery and hiatus hernia repair when peptic strictures were more prevalent which caused “short esophagus” 37. The reported incidence of short esophagus in published series of PEH ranges widely from 2 to 80% 26,38. The use of Collis gastroplasty also ranges widely with some units reporting prevalence of up to 66% 7,11, 39. An esophageal length < 2cm was uncommon in this current study (12%) and Collis gastroplasty was largely abandoned throughout this series which is a similar trend to other reports 11,40. Short esophagus in PEH probably was associated with lesser mediastinal dissection as the rate has diminished over time. It was not found to be significantly associated with hernia recurrence in this series as other factors such as absence of “composite repair” and hiatus closure under tension were more significant. The concept of short esophagus may not be as critical as once thought, given that fairly low recurrence rates were achieved in this study largely without Collis gastroplasty use, which is similar to other contemporary series, suggesting surgical technique improved over time 11,40.

Most surgeons place sutures primarily in the posterior hiatus and behind the esophagus when closing the diaphragmatic hiatus. It has been observed in studies, including a video analysis of over 100 reoperations for hiatus hernia repairs that recurrences most often occur in the anterior hiatus 28,41. Recurrences through the anterior hiatus are thought to be secondary to dilatation, rather than disruption or failure of the hiatal suture line 28. Deficiency of the central tendon may be the primary mechanism for anterior crural defects as they have been shown to increase over time 42. “Telescoping” of the cardio-esophageal junction through a dilated hiatus and fundoplication, frequently referred to as “slipped wrap”, could possibly be reduced with a “composite repair”. This approach, involving fixation of cardio-esophageal junction to the right crus along with the fundoplication, was shown to significantly reduce the risk of hernia recurrence in this series.

Hiatus closure under tension was identified as a significant risk factor for recurrence in this series. This is potentially a critical aspect of the repair if hiatus dilatation is one of the main mechanisms of recurrence. The technical aspects of achieving a low tension hiatus repair and calibration of the hiatus varies between surgeons 17,43. The number of anterior, posterior, and total crural sutures were not significant predictors of recurrence in this study. It would seem the number of sutures in hiatal repair was not an adequate surrogate of hiatal tension, which was predictive of increased recurrence rates. Perception of hiatal tension however could be used to adapt technique once the risk factor is identified.

Strengths of this study include the large number of patients with giant PEH from a single institution, the prospective nature of the data, with postoperative follow-up consisting of both objective and subjective data. It is limited by missing data, particularly with intra-abdominal esophageal lengths and QOL surveys, which may introduce bias into the analysis. A more detailed description of the type of recurrence to include information such as the proportion of “slipped wraps” was not possible due to incomplete data. There was no “control” preoperative endoscopy or barium swallow available for all the patients. All patients had total reduction of stomach at surgery. In this way, all hernias detected on postoperative endoscopy or barium swallow were therefore recurrent. Some, however, may have recurred before objective review. The follow-up time is also not uniform, with symptomatic patients arguably more likely to return for review compared with patients who remained asymptomatic which may falsely degrade results. Follow-up was significantly shorter, as expected, in the “composite repair” group as those patients were operated later in the study period.

The multifactorial nature of anatomical recurrence makes it a complex issue to prevent. Although laparoscopic repair of giant PEH is safe and effective for symptom relief, it remains a complex operation with room for further refinement when anatomical recurrence is used as a measure. Age < 70 years and Barrett’s esophagus were associated with recurrence. Knowledge of these preoperative patient-related factors could help with patient selection, advice, and informed decision-making. Surgeons could have more control over prevention of recurrence by correct application of established operative-related factors including adequate intra-abdominal esophageal length, minimal tension crural closure, fundoplication, and potentially placement of anterior hiatal suture(s) cognisant of the possible anterior dilatation of the hiatus. Use of a “composite repair” could be added to this armamentum. Refinement of operative factors for this operation is an ongoing process, but this current approach with laparoscopic non-mesh repair has yielded non-inferior results.