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Laparoscopic Hiatal Hernia Repair

Crural Closure with Nissen or Toupet Fundoplication

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Genel Cerrahi department. Book Appointment →

What is Laparoscopic Hiatal Hernia Repair?

Laparoscopic hiatal hernia repair is a minimally invasive operation that corrects herniation of stomach (and rarely other abdominal organs) into the thoracic cavity through a widened esophageal hiatus.

Hiatal hernias are classified into type I (sliding, gastroesophageal junction above diaphragm), type II (pure paraesophageal, GE junction below), type III (mixed), and type IV (other organs herniated alongside stomach).

Surgical components: hernia sac reduction and excision, complete mediastinal mobilization of the esophagus to achieve ≥3 cm intra-abdominal length, crural approximation with non-absorbable sutures (selective biologic mesh reinforcement in large defects), and anti-reflux fundoplication.

Fundoplication options: Nissen 360° wrap for normal motility, Toupet 270° posterior partial wrap for impaired motility, Dor 180° anterior wrap (less common), or magnetic sphincter augmentation in selected cases.

Symptoms

Pre-operative symptoms: heartburn, regurgitation, dysphagia, chest pain, postprandial fullness, and early satiety
Anemia and chronic occult bleeding from Cameron erosions in large hernias
Respiratory symptoms: chronic cough, asthma, recurrent pneumonia from microaspiration
Acute presentation in paraesophageal hernia: incarceration with severe chest or abdominal pain, vomiting, gastric volvulus (Borchardt triad: epigastric pain, retching without vomiting, inability to pass NG tube)
Postoperative concerns: dysphagia (especially first 6 weeks), gas-bloat syndrome, recurrent hernia, vagal injury, slipped Nissen wrap
Long-term: persistent or recurrent reflux, dysphagia requiring dilation, hernia recurrence (10–30% over 5 years for large hernias)

Risk Factors

Obesity, especially central adiposity
Aging with diaphragmatic and ligamentous laxity
Chronic raised intra-abdominal pressure (chronic cough, constipation, heavy lifting, pregnancy)
Connective tissue disorders (Ehlers-Danlos)
Prior gastric or hiatal surgery
Female sex (more common in paraesophageal hernias) and family history

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent heartburn or regurgitation despite optimized PPI therapy
  • Dysphagia, especially with weight loss or anemia
  • Acute severe chest or epigastric pain in known hiatal hernia (suspect incarceration or volvulus)
  • Recurrent aspiration pneumonia or worsening asthma in patients with reflux
  • Postoperative persistent dysphagia, recurrent reflux, or chest pain

Treatment Methods

01
Pre-operative assessment: upper endoscopy, contrast esophagram, esophageal manometry to guide fundoplication choice, 24-hour pH or impedance monitoring in unclear cases
02
Surgical principles: full hernia sac reduction and excision, circumferential mediastinal esophageal mobilization for ≥3 cm intra-abdominal length, posterior crural closure with non-absorbable sutures, selective Collis gastroplasty for short esophagus
03
Mesh reinforcement: selective absorbable biologic mesh (porcine SIS, bovine pericardium) considered in defects >5 cm to reduce recurrence; permanent synthetic mesh avoided due to erosion risk
04
Fundoplication selection: Nissen for normal manometry; Toupet for ineffective motility, achalasia variants, or scleroderma; consider partial wrap if dysphagia risk is high
05
Enhanced recovery after surgery (ERAS) pathways: clear liquid diet on day 1, soft diet for 6 weeks, multimodal analgesia, early discharge
06
Postoperative dietary instructions: small frequent meals, avoid carbonation, smoking, and large meals; prokinetics or anti-emetics as needed
07
Postoperative dilation for persistent dysphagia beyond 6 weeks; revisional surgery for recurrent hernia, slipped wrap, or persistent reflux
08
Long-term surveillance: clinical follow-up at 1, 6, and 12 months; reassessment for recurrent symptoms with endoscopy or imaging if needed

Which Department to Visit?

You can visit our Genel Cerrahi department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.