Beyond uniform repair: making operative intent explicit in large paraesophageal hernias

Large paraesophageal hernias represent a heterogeneous clinical entity, with variation in anatomical configuration, symptom profile, esophageal physiology, and patient-related operative risk. Unlike many other heterogeneous surgical conditions, a single anatomical problem may compromise multiple functional systems simultaneously, including gastric transit, reflux physiology, and respiratory function. Despite this multi-system involvement, contemporary literature and practice frequently evaluate these patients as a single group, applying uniform operative paradigms and outcome measures that do not account for differing operative priorities. We propose a phenotype-based conceptual framework to structure operative prioritization based on four preoperative domains: anatomical configuration, dominant clinical presentation, esophageal physiology, and patient-related risk. Integration of these domains identifies the dominant clinical driver shaping operative priorities in the individual patient, anchored in the factor that most impairs quality of life and most strongly motivates the expectation of benefit from surgery. Four phenotypes are described-mechanical, reflux-dominant, respiratory, and risk-constrained-with the risk-constrained phenotype functioning as a hierarchical modifier rather than a competing functional pattern. Within this framework, outcomes are interpreted in relation to operative intent rather than uniform endpoints such as radiological recurrence. This approach supports context-specific interpretation of outcomes and enables surgical strategies to be evaluated against the clinical objective they are intended to achieve. Further refinement will follow through structured consensus and prospective collaborative evaluation.