PD06.02. Giant Para-Oesophageal Hernia Repair: 25-Year Experience With Crural Repair With or Without a Mesh, Gastropexy and Selective Anti-Reflux Procedure

Abstract

Benign Disease: Gastro-Esophageal Reflux and Hiatal Hernia Giant Para-oesophageal hernia (PEH), or "large hiatus hernia", is less common but more concerning when symptomatic, Patients may present with post-prandial pain, vomiting, shortness of breath, reflux or dysphagia or associated anaemia. PEH is commoner in elderly with co-morbidity and there is reluctance to referral for surgery. Symptomatic PEHs are repaired electively given the risk of incarceration, volvulus or ischaemia. The optimal surgical components of PEH repair, specifically whether an anti-reflux procedure is routinely required, remains debated. We evaluated long-term outcomes of GPEH repair using crural closure with or without a mesh plus gastropexy with a selective anti-reflux-procedure. A retrospective analysis of prospectively collected data of patients undergoing elective or emergency GPEH repair between January 2001 and March 2026 was performed. Procedure involved hernial sac dissection, reduction of contents and hiatal reconstruction with crural closure. Mesh reinforcement was used selectively but gastropexy was performed routinely. An anti-reflux procedure (Nissen or Toupet fundoplication) was performed selectively, only where gastro-oesophageal reflux was objectively confirmed by pre-operative oesophageal manometry, 24-hour pH monitoring and upper gastrointestinal endoscopy. Robotic assistance was employed in the later part of the series. Outcomes assessed included symptom resolution, post-operative complications, length of hospital stay, 30-day mortality, and radiological and clinical recurrence with very long term follow up. Quality of life (QoL) was evaluated using the validated SF-36 questionnaire pre- and post-operatively. Respiratory function (FVC and FEV1 as percentage predicted) and haemoglobin were compared using the Wilcoxon signed-rank test. 332 patients (211 female, median age 67 years, range 20–88) underwent GPEH repair. Presenting features included dysphagia (9.5%), shortness of breath (38%), reflux symptoms (24.7%) with 47% anaemic. Emergency surgery was required in 30 cases (9%). A minimally invasive approach was achieved in 307 (92.4%): laparoscopic in 255 (76.8%) and robotic assisted in 52 (15.7%); 25 (7.5%) were open or converted. Crural closure was performed in all; gastropexy in 91 %; selective fundoplication in 49.4%; mesh in 19.5%. Median post-operative stay was 3 days (laparoscopic), 3 days (robotic) versus 10 days (open; p<0.001). There was 2 (0.6 %) 30-day mortality. Median follow up was 96 months (range 3 months to 264 months). Respiratory function and haemoglobin improved significantly during follow up compared to pre-op values. QoL improved significantly across all SF-36 domains. Fundoplication was associated with significantly higher symptomatic recurrence (83.3% vs 12.5% without fundoplication). GPEH repair with crural closure and gastropexy is safe and effective across all age groups, including emergency presentations. Radiological recurrence is common and not associated with symptoms in many. Fundoplication strategy based on objective pre-operative reflux evaluation is strongly recommended, as routine anti-reflux procedure was associated with significantly higher symptomatic recurrence. This approach reliably improves quality of life, respiratory function and anaemia. Our 25-year data support selective — rather than routine — fundoplication as the optimal strategy in GPEH repair.