Surgical treatment of hiatal hernias of types II–IV. Ten years of experience

INTRODUCTION. Hiatal hernias occur in 10 % of young adults and 50–60 % of older adults. Types II–IV hernias account for 15 % of cases. Characteristics of this type of anatomical abnormality include a large hiatal opening, significant destruction of the ligamentous apparatus that holds the stomach in place, and, often, a shortened esophagus. The clinical significance and indications for surgical treatment of types II–IV hiatal hernias are determined by the resulting dysfunction of organs displaced into the mediastinum due to their rotation or compression within the hiatal opening. A high recurrence rate, reaching 20–40 % and even 60 %, remains an unresolved issue in this area of practical medicine. This situation dictates the need for solutions.
METHODS AND MATERIALS. This article presents an analysis of the long-term treatment outcomes of 330 patients with types II–IV esophageal hernias. These patients were treated in the Thoracic Surgery Department of the Murmansk Regional Clinical Hospital named after P. A. Bayandin. The patients were divided into two groups. The retrospective group consisted of 150 patients who underwent surgery from 2013 to 2017 according to generally accepted principles. For hiatal hernias up to 5 cm in size, they were repaired using their own tissues; for larger hiatal hernias, they were reinforced with a mesh prosthesis anterior and posterior to the esophagus. Fundoplication was performed to prevent gastroesophageal reflux. The prospective group included 180 patients who underwent surgery from 2018 to 2024, taking into account the analysis of unsatisfactory treatment outcomes in the retrospective group. The modified strategy focused on esophageal shortening, a significant factor in the primary occurrence of this type of hernia and its recurrence after surgery. In patients with esophageal shortening in the retrospective group, the hiatal orifice was always repaired using the patient’s own tissue, and the fundoplication cuff was formed in the mediastinum. In patients with normal esophageal length, the strategy was the same as in the retrospective group.
RESULTS. The duration of surgery, hospital stay, and incidence of intraoperative and early postoperative complications were similar in both groups. Comparison of long-term treatment outcomes revealed a decrease in the incidence of unsatisfactory outcomes (anatomical and clinical recurrence) to 11.4 % in the prospective group compared to 26.7 % in the retrospective group.
CONCLUSION. Changing surgical treatment tactics for types II–IV esophageal hernias, taking into account the shortening of the esophagus, has reduced the incidence of unsatisfactory surgical outcomes by more than half.

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