Overview
Definition:
Recurrent paraesophageal hernia (PEH) occurs when the stomach or other abdominal viscour organs slide into the chest through the diaphragmatic hiatus after a previous surgical repair
Posterior cruroplasty with mesh is a common technique employed to reconstruct the diaphragmatic hiatus and prevent recurrence, particularly in large or complex hernias.
Epidemiology:
Recurrence rates after hiatal hernia repair vary widely, ranging from 5% to 20% or more, depending on surgical technique, patient factors, and definition of recurrence
PEH recurrence is more common in larger hernias and those associated with a wide diaphragmatic hiatus
Factors like obesity, pregnancy, and strenuous activity can contribute to recurrence.
Clinical Significance:
Recurrent PEH can lead to significant morbidity including dysphagia, regurgitation, reflux symptoms, respiratory compromise, and severe complications like gastric volvulus, strangulation, or perforation
Accurate diagnosis and timely surgical intervention are crucial to prevent life-threatening outcomes and improve patient quality of life
This topic is highly relevant for surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Patients may present with a recurrence of pre-operative symptoms such as chest pain
Postprandial fullness or early satiety
Regurgitation of food or undigested material
Dysphagia, particularly for solids
Nausea and vomiting
Occasional respiratory symptoms like cough or shortness of breath
Acute severe epigastric or chest pain may suggest gastric volvulus or strangulation.
Signs:
Physical examination findings may be nonspecific
Abdominal distension can be present in cases of gastric outlet obstruction or volvulus
Palpation may reveal tenderness in the epigastric region
Auscultation might reveal decreased bowel sounds, especially with complications
Vital signs may be normal, or show tachycardia and hypotension in cases of hemodynamic compromise.
Diagnostic Criteria:
Diagnosis is primarily based on clinical presentation confirmed by imaging
No specific formal diagnostic criteria for recurrence exist beyond imaging confirmation of re-herniation of abdominal contents into the chest
However, the presence of recurrent symptoms post-operatively in a patient with a history of PEH repair strongly suggests recurrence.
Diagnostic Approach
History Taking:
A thorough history should elicit details of the initial hernia repair (date, surgeon, technique used)
Focus on the nature, timing, and severity of recurrent symptoms
Ask about prior comorbidities, lifestyle factors (obesity, smoking), and adherence to post-operative care
Red flags include severe pain, inability to tolerate oral intake, or signs of respiratory distress, suggesting acute complications.
Physical Examination:
A comprehensive abdominal and thoracic examination is essential
Assess for abdominal distension, tenderness, and guarding
Listen for bowel sounds
Examine the chest for respiratory abnormalities
A digital rectal examination may be useful to rule out other causes of abdominal pain or obstructive symptoms.
Investigations:
Upper gastrointestinal endoscopy is crucial to assess the integrity of the repair, identify the extent of herniation, and evaluate for mucosal abnormalities or complications
Barium swallow (esophagogram) is highly sensitive for demonstrating the defect and the degree of herniation, and is essential for evaluating the anatomy and function of the esophagus and stomach
CT scan of the chest and abdomen can provide detailed anatomical information, especially for large or complex recurrences, and assess for complications
Manometry may be considered in selected cases to assess esophageal motility.
Differential Diagnosis:
Other causes of chest pain or upper abdominal discomfort post-surgery include: peptic ulcer disease, esophageal stricture, GERD, biliary colic, pancreatitis, and cardiac causes
Dysphagia can also be due to functional esophageal disorders or external compression
Distinguishing recurrence from these requires careful clinical correlation and appropriate investigations.
Management
Initial Management:
For asymptomatic or minimally symptomatic recurrence, conservative management including dietary modifications and acid suppressants may be considered
However, symptomatic recurrence typically requires surgical intervention
Patients presenting with signs of acute gastric volvulus or strangulation require immediate surgical decompression and repair.
Surgical Management:
The primary management for symptomatic recurrent PEH is reoperation
Key elements include: mobilization of the stomach from the mediastinum
Excision of the previous repair or scar tissue
Crural separation and identification of the diaphragmatic hiatus
Posterior cruroplasty to reduce the size of the hiatus
Placement of a prosthetic mesh to reinforce the diaphragmatic crura and prevent recurrence
Fundoplication (e.g., Nissen or Dor) is often performed to address associated reflux symptoms
Transhiatal or transthoracic approaches can be used, with laparoscopic approaches becoming increasingly common.
Postoperative Care:
Postoperative care involves pain management
Gradual resumption of oral intake, starting with liquids
Monitoring for complications such as pneumonia, wound infection, bleeding, or leak
Nutritional support if oral intake is delayed
Patients are typically discharged once they are tolerating a diet and ambulating
Long-term follow-up is essential.
Complications
Early Complications:
Bleeding and hematoma formation
Wound infection
Pneumonia and atelectasis
Esophageal or gastric injury during dissection
Diaphragmatic injury
Esophageal leak
Staple line dehiscence
Gastric outlet obstruction.
Late Complications:
Mesh-related complications including infection, erosion, or migration
Persistent or recurrent GERD
Dysphagia or esophageal stricture
Recurrence of hernia despite mesh repair
Chronic pain
Gastric distension
Dumping syndrome.
Prevention Strategies:
Meticulous surgical technique with adequate dissection and careful handling of tissues
Appropriate selection of mesh material and its secure fixation
Careful tension-free closure of the hiatus
Judicious use of fundoplication
Strict adherence to post-operative dietary guidelines
Patient selection to minimize risk factors for recurrence.
Prognosis
Factors Affecting Prognosis:
The success of recurrent PEH repair is influenced by the size of the hiatus, the extent of previous scarring, the patient's overall health, and the surgeon's experience
Larger defects and extensive adhesions can make the repair more challenging and increase the risk of recurrence
Prompt surgical intervention for acute complications significantly improves outcomes.
Outcomes:
With modern surgical techniques, including mesh reinforcement, recurrence rates for PEH repair can be significantly reduced
Most patients experience relief from their symptoms
However, a small percentage may still experience recurrence or develop other postoperative issues
Long-term relief from reflux symptoms depends on the success of the fundoplication, if performed.
Follow Up:
Long-term follow-up is recommended to monitor for recurrence, assess symptom resolution, and manage any late complications
This typically involves regular clinical evaluations and may include periodic endoscopic assessments or barium swallows, especially in high-risk patients or if symptoms recur
Nutritional counseling may be beneficial.
Key Points
Exam Focus:
Understand the anatomical defect in PEH
Recognize the importance of posterior cruroplasty and mesh reinforcement
Differentiate between symptoms of simple recurrence and acute complications like gastric volvulus
Recall the indications and contraindications for mesh use in hernia repair
Know the potential early and late complications of recurrent hernia repair.
Clinical Pearls:
Always suspect recurrent PEH in patients with new or worsening upper GI symptoms post-hiatal hernia repair
Barium swallow is indispensable for pre-operative planning of recurrent PEH repair
Careful dissection is key to avoid injury to adjacent structures
Secure mesh fixation is paramount for long-term success and prevention of recurrence
Consider anti-reflux procedure (fundoplication) in most cases of symptomatic recurrent PEH.
Common Mistakes:
Inadequate reduction of the hiatal defect
Overly aggressive dissection leading to injury
Failure to use mesh in large or recurrent defects
Insecure mesh fixation or inappropriate mesh placement
Underestimation of the risk of gastric volvulus in large PEH
Insufficient attention to anti-reflux management post-repair.