Hiatus hernia is a condition where part of the stomach herniates into the thoracic cavity through the esophageal hiatus of the diaphragm. While small hernias may remain asymptomatic and often require only medical management, large hiatus hernias can lead to severe gastroesophageal reflux disease (GERD), dysphagia, regurgitation, chest discomfort, or even respiratory symptoms due to compression. In his lectures, Dr. R. K. Mishra, a world-renowned laparoscopic surgeon and educator at World Laparoscopy Hospital, has extensively explained the principles, techniques, and outcomes of laparoscopic repair of large hiatus hernia, emphasizing its role as the gold standard treatment.

Understanding Large Hiatus Hernia

Large hiatus hernia, also known as paraesophageal hernia when a significant portion of the stomach migrates into the chest, is particularly challenging. Patients may present with chronic reflux, iron deficiency anemia due to occult bleeding, postprandial fullness, or even volvulus of the stomach in rare cases. Dr. Mishra highlights that laparoscopic repair not only relieves symptoms but also prevents life-threatening complications.

Principles of Surgical Repair

According to Dr. Mishra’s lecture, the core objectives of laparoscopic repair include:

Reduction of Herniated Stomach – Bringing the stomach and any herniated viscera back into the abdominal cavity.

Excision of Hernia Sac – To reduce recurrence rates and restore normal anatomy.

Crural Repair (Cruroplasty) – Closing the enlarged esophageal hiatus with non-absorbable sutures.

Fundoplication – Performing an anti-reflux procedure (commonly Nissen or Toupet fundoplication) to prevent reflux.

Reinforcement with Mesh (if needed) – In very large hernias or weak diaphragmatic tissues, a biological or synthetic mesh may be used to reinforce the hiatus.

Dr. Mishra emphasizes that meticulous adherence to these principles is key to long-term success and recurrence prevention.

Laparoscopic Surgical Technique

Dr. R. K. Mishra explains the surgical steps in a systematic way:

Port Placement – Typically, 4–5 ports are used: one for the laparoscope and others for working instruments. The patient is positioned in reverse Trendelenburg to allow gravity-assisted retraction of the viscera.

Dissection and Mobilization – Adhesions and the hernia sac are carefully dissected from the mediastinum, taking care not to injure the esophagus or pleura. The stomach is fully mobilized and brought back into the abdomen.

Crural Approximation – The diaphragmatic crura are approximated posteriorly using interrupted non-absorbable sutures. Dr. Mishra stresses that the tension-free closure of the hiatus is essential to prevent recurrence.

Fundoplication – A 360-degree Nissen fundoplication is commonly performed, though in certain cases, a partial wrap like Toupet is preferred, especially if esophageal motility is poor.

Mesh Reinforcement – In very large hiatal defects, where sutures alone may not suffice, a biological mesh is often placed to strengthen the repair. Dr. Mishra notes that mesh use must be carefully selected to minimize complications like erosion.

Advantages of Laparoscopic Repair

Dr. Mishra outlines several advantages of laparoscopic repair compared to traditional open surgery:

Minimally Invasive: Smaller incisions, less pain, and faster recovery.

Restoration of Anatomy: Effective repositioning of the stomach and closure of the hiatus.

Symptom Relief: Most patients experience significant improvement in GERD symptoms, dysphagia, and regurgitation.

Shorter Hospital Stay: Patients are usually discharged within 2–3 days.

Cosmetic Benefit: Minimal scarring due to small port sites.

Challenges in Large Hiatus Hernia Repair

Despite its advantages, Dr. Mishra points out that laparoscopic repair of large hiatus hernia can be technically demanding:

Risk of Recurrence: Especially if the crura are weak or if the hernia sac is incompletely excised.

Esophageal Length Issues: In some patients, the esophagus is short, requiring a Collis gastroplasty.

Risk of Injury: The proximity to the vagus nerves, pleura, and major vessels makes dissection delicate.

Mesh-Related Complications: Though rare, meshes can erode into the esophagus or stomach if not carefully selected.

Outcomes and Patient Satisfaction

Dr. Mishra cites evidence and his own vast clinical experience showing that laparoscopic repair provides durable relief in most patients. Success rates exceed 90% in terms of symptom control and quality of life improvement. Recurrence rates have reduced significantly with meticulous dissection, complete sac excision, and selective mesh reinforcement. Patient satisfaction is generally high due to rapid recovery, minimal pain, and effective symptom relief.

Teaching and Training Emphasis

As a global educator, Dr. Mishra underscores the importance of structured training for surgeons. At World Laparoscopy Hospital, trainees are taught not just the technical aspects of hiatus hernia repair but also patient selection, perioperative management, and complication handling. His lectures serve as a valuable resource for both practicing surgeons and postgraduate trainees seeking advanced laparoscopic skills.

Conclusion

Dr. R. K. Mishra’s lecture on laparoscopic repair of large hiatus hernia provides a comprehensive roadmap for surgeons. By emphasizing meticulous dissection, secure crural closure, and appropriate use of fundoplication and mesh, he highlights how this minimally invasive approach has transformed the management of a challenging surgical problem. Laparoscopic repair not only restores anatomy but also relieves symptoms, prevents complications, and offers patients a safe and effective long-term solution.