Re-operative surgery after paraesophageal hernia repair: narrative review

to review the approach to revisional paraesophageal hernia repair. Background: Recurrence after a successful paraesophageal hernia repair is not uncommon and appears to be a time dependent phenomenon. Revisional surgery is required in approx. 15% of patients and is associated with increased morbidity and mortality. Challenging aspects of revisional surgery include distorted anatomy, adhesions and possible presence of mesh which increases risk of esophageal perforation, gastric perforation, vagal nerve injury and splenic injury. Methods: We reviewed our own institutional experience and recent literature for approach, techniques and outcomes of revisional paraesophageal hernia surgery. Conclusions: A thorough investigation can reveal the etiology of failure/symptoms and is vital in formulating an operative plan. Manometry, esophagogastroduodenoscopy (EGD), computed tomography (CT) scan, esophagogram, gastric emptying studies and pH studies all form part of the work-up. Transabdominal approaches (minimally invasive or open) are the most common. Left transthoracic and thoracoabdominal are options in case of a hostile abdomen. Key operative steps in redo repair include reduction of hernia, excision of remaining sac if present, restoring correct anatomy, ensuring adequate intra-abdominal esophagus, possible esophageal lengthening, and robust crural closure with revision of fundoplication. Cautious post-op management and slow diet advancement is applied with yearly monitoring for early identification of issues.