Management of Recurrent Paraesophageal Hernia

Recurrent paraesophageal hernias (rPEH) represent a clinical and surgical challenge. Even with a relatively high incidence, most of them are minimally symptomatic, and the need for reoperation is low. For those patients who are candidates for surgery, laparoscopic revision is a feasible and safe technique although there are other treatment options available. This article provides an overview of the definition, mechanisms of recurrence, epidemiology, clinical presentation, and indications for treatment of rPEH, as well as an overview of the surgical management options and a description of the technical principles of the repair and/or resection. Surgeons should consider multiple factors when deciding the appropriate treatment of patients with rPEH, and all of them require a complete and comprehensive evaluation. The surgical options need to be individualized and include a redo PEH repair and revisional fundoplication, a partial or total gastrectomy with Roux-en-Y reconstruction, or an esophagectomy. There are key steps during the surgical repair that contribute to a successful operation and also auxiliary techniques that can improve postoperative outcomes. After laparoscopic redo most patients have improvement of their symptoms and an acceptable rate of perioperative complications when they are performed by experienced foregut surgeons. In obese patients with rPEH, bariatric surgery can be the best treatment option. Laparoscopic reoperative management should be considered in symptomatic patients who are not controlled with maximal nonoperative therapy, after a thorough work-up and appropriate counseling. In cases with multiple hernia repairs, it is important to consider alternative operations.