Association Between Large Hernia Size and Severe Postoperative Complications After Type III/IV Hiatal Hernia Repair

Introduction Large Type III and IV esophageal hiatal hernias often require surgical repair because of organ herniation and related symptoms. Although the procedure is benign, it is associated with a significant risk of complications, particularly in large hernias. This study aimed to clarify risk factors for severe postoperative complications in patients requiring reoperation following surgical repair of Type III and IV esophageal hiatal hernias. Methods We retrospectively reviewed 34 patients who underwent repair of Type III (n = 21) or IV (n = 13) esophageal hiatal hernias (2014-2024). Clinical data and preoperative computed tomography (CT) measurements of the hiatal length and hernial sac area were analyzed. Operative time was dichotomized at the cohort median, and variables with p < 0.10 in univariable tests were entered into a Firth's penalized logistic regression to identify predictors of prolonged operative time. Results Severe postoperative complications (Clavien-Dindo Grade IIIb) occurred in three patients, all with Type IV hernias and larger hiatus lengths and hernia sac areas. Hernia sac area correlated positively with operative time (ρ = 0.60, p < 0.001). In multivariable analysis using Firth's penalized logistic regression, hernia sac area was independently associated with prolonged operative time (OR 15.9, p < 0.001), consistent with univariable findings. Conclusion A large hernia size was associated with prolonged operative time and increased risk of severe postoperative complications. Preoperative assessment of hernia size may facilitate surgical planning and improve outcomes.