Reflections on surgery for hiatal hernia

Gastroesophageal reflux disease and hiatal hernia are highly prevalent, chronic, and heterogeneous disfunctions with a profound impact on patient’s quality of life. Impairment of the antireflux barrier -which includes the lower esophageal sphincter, the gastroesophageal flap valve, and the crural diaphragm- is the main pathophysiological factor responsible for symptoms and complications. Accurate diagnosis mandates a comprehensive multidisciplinary assessment including upper endoscopy, high-resolution manometry, barium esophagram, and ambulatory pH or pH-impedance monitoring to characterize anatomical defects, motility abnormalities, and reflux severity. Well selected individuals with refractory or complicated reflux disease, and those with large hiatal hernia and intrathoracic stomach, may benefit from laparoscopic surgical management including crural repair and fundoplication to restore the antireflux barrier. Nissen fundoplication is highly effective in controlling reflux but it may be associated with postoperative dysphagia and gas-bloat syndrome. Partial fundoplication can offer comparable reflux control with reduced adverse effects, especially in patients with impaired esophageal motility. Novel devices such as the LINX and the RefluxStop show promise in augmenting the lower esophageal sphincter with favorable safety profiles. The role of mesh reinforcement for hiatal repair remains contentious due to unpredictable outcomes and risk of complications. Robotic-assisted surgery offers enhanced technical precision but has yet to demonstrate significant clinical superiority and incurs greater costs compared to laparoscopy. Artificial intelligence applications are emerging as valuable adjuncts for preoperative planning, intraoperative guidance, and postoperative monitoring, potentially improving procedural standardization and surgical outcomes.