Objectives: To determine the influence of hiatal hernia size and the laparoscopic fundoplication technique on the rate of hernia recurrence.
Patients and methods: The preoperative, operative, and postoperative observational data of 381 patients operated on at the Department of Surgery of Kaunas University of Medicine during the period of 1998-2004 for hiatal hernia complicated with gastroesophageal reflux were analyzed. The surgery technique (Nissen or Toupet operation) was chosen independently of the hernia size. The radiological investigation of the esophagus-stomach using barium contrast as well as esophagogastroduodenoscopy and biopsy was performed for all patients before the surgery. The subjective and objective assessment of the patients' health status was investigated before and no less than 12 months after surgery. If the disease symptoms remained or new ones (i.e. pain behind the sternum, dysphagia, etc.) occurred after surgery, the hernia recurrence was suspected. The radiological investigation of the esophagus-stomach using barium contrast, as well as esophagogastroduodenoscopy and biopsy were performed at the consultative outpatient clinic. The hernia recurrence was confirmed after performing these two investigations. When analyzing the results, the patients were divided into two groups: Group 1--patients with small hiatal hernia (grade 1 and 2 hernia according to radiological classification), Group 2--patients with large hiatal hernia (grade 3 and 4 hernia according to radiological classification).
Results: A total of 272 (71.4%) patients had small hiatal hernia, and 109 (28.6%) patients had large ones. Hernia recurrence was diagnosed in 7 (2.58%) patients in Group 1, while in Group 2, 11 (10.1%) patients had hernia recurrence (P<0.05). Laparoscopic Nissen fundoplication was performed in 287 (75.4%) patients, after which 14 (4.98%) patients had hernia recurrence, while Toupet fundoplication was performed in 94 (24.6%) patients, after which 4 (4.3%) patients had hernia recurrence (P>0.05).
Conclusions: The recurrence rate of hiatal hernia after laparoscopic fundoplications is significantly higher in patients with large hernias (grade 3 and 4 according to radiological classification). The surgery technique (Nissen or Toupet fundoplication) was not a significant factor affecting the recurrence rate of hiatal hernia.