Narrative review of management controversies for paraesophageal hernia

To review management controversies in paraesophageal hernia and options for surgical repair.

Paraesophageal hernia is an increasingly common problem. There are controversies over whether and when paraesophageal hernias should be surgically repaired. In addition, if these hernias are to be repaired, the method of repair, need for mesh reinforcement, need for fundoplication, and need for gastropexy are not uniformly accepted.

Recent literature was reviewed on need for repair, approach (open, laparoscopic or robotic surgery), method of repair (primary suture, use of relaxing incisions, use of mesh reinforcement), materials and configuration of mesh reinforcement, need and type of fundoplication, and need for gastropexy, with emphasis on surgical outcomes.

The extant literature suggests that paraesophageal hernia should be approached in a patient-centered, precision medicine manner. In general, hernia reduction, sac excision and primary suture approximation of the hiatal crura are mandatory. Use of mesh should be based on individual risk factors; if mesh is used, biological meshes appear to have a more favorable safety profile, with the "reverse C" or keyhole configuration allowing for increase in crural tensile strength at it most vulnerable areas. Use and choice of fundoplication or magnetic sphincter augmentation should be based on individual considerations. Finally, gastropexy is generally ineffective and should be used only in extreme circumstances.