Paraesophageal Hernia Repair with Toupet Fundoplication

Paraesophageal hernia (types II to IV) involves migration of the gastric fundus and other viscera through the esophageal hiatus alongside the gastroesophageal junction. Surgical repair is recommended in symptomatic patients to prevent volvulus, gastric incarceration, and respiratory compromise. Standard laparoscopic operation includes complete reduction of the hernia, resection of the sac, mediastinal esophageal mobilization, primary or mesh-augmented crural closure, and an antireflux fundoplication.

Toupet fundoplication is a partial 270-degree posterior wrap performed when esophageal motility is impaired (peristalsis amplitude under 30 mmHg, scleroderma, achalasia overlap) or when minimizing the risk of postoperative dysphagia and gas-bloat syndrome is preferred over the maximal reflux control of a 360-degree Nissen wrap. It also helps anchor the gastroesophageal junction below the diaphragm.

Outcomes show 85 to 90 percent symptom relief at five years, with hernia recurrence rates of 10 to 15 percent and reoperation under 5 percent. Mesh use at the hiatus reduces early recurrence but introduces small risks of erosion. ERAS protocols, opioid-sparing analgesia, and same-day or next-day discharge are increasingly standard.