The evaluation of patients with recurrent hiatal hernias requires the surgeon assess the severity of patient symptoms. Several studies report that patients have minimal symptoms and good quality of life despite high rates of radiographic recurrent hiatal hernia [1, 24–26]. Other studies show relatively low rates of recurrence, however higher rates of symptoms among those patients identified with a recurrent hernia [27, 28]. In both groups, the most common indication for operative management of recurrent hiatal hernia is symptoms insufficiently managed with non-operative therapies (e.g. acid suppression medication and esophageal dilation).

Andujar and colleagues retrospectively reviewed their experience with laparoscopic PEH repair in 166 patients [25]. A barium esophagram was completed in 120 patients (72 %) at a mean of 15 months postoperatively and revealed 30 patients (25 %) with recurrent hiatal hernia. In 18/30 patients, pre- and postoperative symptom scores were available. Despite the presence of a recurrent hiatal hernia, these patients had significant improvement in heartburn, regurgitation, dysphagia, and chest pain at 6 and 24 months postoperatively. Furthermore, when these 18 patients with recurrent hiatal hernias were compared to patients without postoperative hiatal hernia (n = 76), there were no differences in symptom severity at 24 months postoperatively. Only three patients with recurrent hiatal hernia required reoperation. In these three patients, the indication for operation was GERD symptoms that were insufficiently improved with medical management.

Lidor and colleagues reported their results of 101 patients who underwent laparoscopic PEH repair [20]. At 12 months postoperatively, 58 patients underwent barium esophagram and an assessment of symptoms and quality of life. Despite a recurrent hiatal hernia rate of 27.6 %, all patients had improvement in reported foregut symptoms. However, when patients with recurrent hiatal hernia were compared to those without hiatal hernia, patients with recurrence had worse symptom scores for early satiety, dysphagia, odynophagia, and bloating/gas. Despite these findings, overall patient satisfaction was reported to be excellent. One patient required reoperation for obstructive symptoms recalcitrant to dilation therapy.

After a patient is identified with a recurrent hiatal hernia, the surgeon must carefully evaluate the patient’s symptoms. In patients with symptomatic recurrent hiatal hernia, a concerted attempt should be made at non-operative management of symptoms. In most cases, proton-pump inhibitor therapy will ameliorate symptoms of GERD. On the other hand, obstructive symptoms are more likely to require operative intervention. In the end, when non-operative therapy fails to provide adequate control of symptoms, reoperative hiatal hernia repair should be considered.

We routinely perform a 360-degree Nissen fundoplication at the time of primary PEH repair, a practice advocated for in the literature by us and others [29, 30]. There are several reasons that we believe a fundoplication is a key step to PEH repair. Theoretically, it provides reinforcement of the hernia repair by securing the stomach below the diaphragm, particularly if the fundoplication is sutured to the diaphragmatic crura, which effectively creates a gastropexy. The fundoplication also provides an additional surface to which adhesions can develop, which may assist to secure the stomach to the hiatus and prevent the gastric body from migrating into the chest.

If a recurrent hiatal hernia develops, an appropriately created fundoplication can be protective against both obstructive and GERD related symptoms. By incorporating the gastric fundus into a fundoplication, the fundus is unable to migrate into the posterior mediastinum where, if it distends, it can create angulation to the esophagus resulting in dysphagia or other obstructive symptoms. If the fundoplication remains intact, even in the setting of a recurrent hiatal hernia, then it often will retain its competency as an anti-reflux valve and counteract GERD symptoms.

For a fundoplication to provide these protective effects, it must be constructed with the correct part of the stomach, and it must be positioned around the distal esophagus. Frequently, recurrent hiatal hernias consist of a mild (2–4 cm) widening of the esophageal hiatus and cephalad displacement of the fundoplication into the posterior mediastinum. If the fundoplication is inappropriately constructed (i.e. fundus sutured to gastric body, or the fundoplication is created too loose or “floppy”) the result is a redundant fundus that lies behind the esophagus. When this occurs, a disproportionately large amount of stomach can herniate through a relatively small recurrent hiatal hernia. The result is a symptomatic recurrent hiatal hernia that is due to a poorly constructed fundoplication rather than a widening of the hiatus, per se.

We believe that our investigation of the long-term outcomes of laparoscopic PEH repair indirectly supports the protective effect of a well-constructed fundoplication [22]. All patients in this study underwent 360-degree Nissen fundoplication. The geometry of our Nissen fundoplication is created by expert foregut surgeons in a very standardized manner, ensuring that only fundus is used. This approach prevents the creation of Nissen that is too loose or “floppy”, decreasing the likelihood of postoperative heartburn and/or obstructive symptoms. In that study, we reported a high rate of recurrent hiatal hernia following primary laparoscopic PEH repair (>50 %). However, the patients with hernia recurrence maintained an overall quality of life similar to patients without recurrence. While heartburn was more common in patients with recurrent hiatal hernia, the severity was usually mild, most patients were adequately controlled on medication, and need for reoperation was rare. We believe that an appropriately constructed Nissen fundoplication minimized the symptoms associated with these recurrent hiatal hernias.

Traditionally, patients found to have large asymptomatic primary PEH were recommended to undergo repair to prevent acute gastric volvulus and the need for emergent repair [31, 32]. Unlike primary PEH, large recurrent hiatal hernias are more likely to be symptomatic and, for that reason, require repair. These severe recurrences almost always are associated with intraoperative evidence of an inadequate primary PEH repair – for example, incomplete sac excision, insufficient mobilization of the esophagus, and/or poor construction of the fundoplication. Therefore, reoperation for these very large recurrent hiatal hernias has a greater likelihood of correcting a persistent anatomic problem and creating a long-term durable repair. While some authors have advocated for routine repair of larger asymptomatic recurrent hiatal hernias [24], compared to primary PEH repair, reoperative hiatal hernia repair is more technically challenging and associated with greater risk. So, the question remains whether size alone should be considered in determining need for recurrent hiatal hernia repair.

As part of our prospective multi-institutional study of laparoscopic PEH repair, we assessed the relationship between recurrent hiatal hernia size and patient symptoms [22]. Recurrent hernia size was measured vertically above the diaphragm using barium esophagram; patient symptoms were assessed using standardized patient questionnaires. Long-term clinical and radiographic data were available for 60 of 108 (56 %) patients. Twenty-six (43 %) patients had a recurrent hernia measuring <20 mm, 14 (24 %) patients measuring 20–39 mm, and 20 (33 %) patients measuring ≥40 mm (though rarely larger). Patients with large (≥40 mm) recurrent hernias had greater heartburn severity compared to patients without hiatal hernia (<20 mm) (p = 0.046). Importantly, operative repair was required in only two of these patients, and symptoms, not size, was the criterion used to determine need for repair.