Laparoscopic hiatal repair with fundoplication is standard but carries risks of dysphagia and gas-related symptoms.
Gastropexy without fundoplication is a less invasive alternative, often used in fragile patients or when formal repair is unsafe.
In a cohort of 30 patients, 30% experienced major postoperative complications; 23% had PEH recurrence requiring redo surgery.
Guideline-Based Recommendations
Diagnosis
Diagnosis of PEH includes clinical symptoms and imaging, with classification by Hill types II-IV.
Management
SAGES guidelines recommend repair of all PEHs, especially with gastric volvulus or obstructive symptoms.
Laparoscopic hiatal hernia repair with fundoplication is widely accepted but may be substituted by gastropexy without fundoplication in high-risk patients.
Monitoring & Follow-up
Postoperative follow-up includes assessment of complications using Clavien-Dindo classification and evaluation of reflux symptoms and quality of life via GERD-HRQL questionnaire.
Risks
Fundoplication carries risks of persistent dysphagia (up to 25%) and gas bloating.
Gastropexy without fundoplication may have a risk of PEH recurrence requiring redo surgery.
Major postoperative complications occurred in 30% of patients in the studied cohort.
Patient & Prescribing Data
30 patients with PEH (median age 72 years), including emergency cases for gastric perforation or ischemic distress
Gastropexy without fundoplication resulted in 75% symptom resolution and 72% patient satisfaction at median 38 months follow-up; 23% required redo surgery for recurrence.
Clinical Best Practices
Perform complete resection of hernia sac and mobilize lower esophagus to achieve 3-4 cm intra-abdominal esophageal length.
Close diaphragmatic hiatus with interrupted non-absorbable sutures reinforced with PTFE pledgets to support fibrosis.
Use gastric calibration tube intraoperatively to avoid hiatal stenosis.
Perform gastropexy by suturing gastric fundus to anterior abdominal wall with non-absorbable barbed suture.
Consider gastropexy without fundoplication in fragile patients or when formal repair is unsafe to minimize surgical trauma and avoid postoperative dysphagia.
