Choosing the best approach for paraesophageal hiatal hernia repair: a narrative review

: The optimal approach for repairing large paraesophageal hernia (PEH) is unclear. Historically, these were initially approached through a transthoracic incision, then shifted to a laparotomy. Now laparoscopy has been the most common approach for at least the past decade, during which time the robotic approach has also increased in utilization. This article reviews the pros and cons of the different approaches, including recurrence rates, morbidity, and mortality. Using this information, we propose a general framework for the utilization of each approach as a reference for surgeons in their clinical decision making and operative planning. Laparoscopic (and/or robotic) approaches are best suited for small PEHs or cases of reflux alone. Robotic technology can aid in crural repair and potentially reduce long-term recurrence compared to traditional laparoscopy, while maintaining the benefits of quicker recovery. A laparotomy should generally be reserved for patients with recurrent PEH and severe intra-abdominal adhesions or urgent situations such as obstruction, gangrene, or conversion from laparoscopy. Due to the high risk of recurrence, patients with larger PEHs (type III or IV) or risk factors for recurrence (obesity, shortened esophagus, chronic cough, or constipation), should be strongly considered for a transthoracic approach. It is unclear if mesh offers benefits long term, but there is a small incidence of catastrophic mesh complications that should also be considered. Non-operative management of PEH, though occasionally utilized for asymptomatic patients, should generally be avoided due to a high risk of PEH-related complications and mortality. 9