Who should be repairing these hernias? Level of expertise?

Hiatal hernias are commonly seen in patients presenting with GERD. Surgical management of patients with hiatal hernias remains a challenge given the lack of general consensus on management and operative technique. This has led to gaps in quality and outcomes of care in these patients. Variable levels of knowledge, experience, and expertise among practitioners has resulted in extreme deviations in preoperative evaluation, procedural technique, follow-up, and outcomes, that led to poor confidence in surgical management of GERD and hiatal hernias. We performed a literature review of contemporary and latest studies compiled in review format. The conclusions we made from our review of the literature were that foregut surgeons need to have a comprehensive understanding of foregut physiology and coordinate a thorough preoperative evaluation including independent interpretation of esophageal physiologic testing and the ability to perform endoscopy. Foregut surgeons should have specialized expertise and training in benign foregut procedures, minimally invasive techniques, and have a commitment to long term follow up. Ideally these complex operations would be completed by a minimally invasive trained surgeon at a high-volume center as improved outcomes and decreased costs have been associated with laparoscopic technique and increased surgeon/hospital volume. A multidisciplinary approach should be utilized when feasible.