Surgery failures in patient who has undergone primary hiatal hernia laparoscopic repair are most commonly associated with recurrent herniation and breakdown of the fundoplication. The surgical techniques used to treat this failure are different: alternatives consist of laparoscopic reoperation, or laparatomic/transthoracic repair. How do you decide this dilemma?
It depends on the case and the experience of the surgeon. The reason why the hiatal hernia is recurring does also matter. Is it a failure only because the diaphragmatic suture line breaks, then laparoscopic redo surgery with mesh implantation is an option. But in cases with wrong indications at primary surgery, you need to have the options to correct all the problems and in these cases open surgery might be - depending on your experience - the better option. E.g. in cases of shortening of the esophageus accompanying Barret's esophageus, the failure is usually not only because of breakdown of the diaphragmatic sutureline, but is also dependant from the true esophageal length, which is too short so you may need a lenghtening procedure.
I agree with Hans and Alberto. Careful selection for a redo is extremely important. I also would always start laparoscopically and have a mesh ready.
I always try redo surgery by laparoscopically first for reccurent of hiatal hernia whethter primary surgery was performed laparoscopic or open. You will be given a wider view by the laparoscope. If a mesh was used for reinforcement of the hiatus, redo surgery must be difficult because mesh will be more and more harder like a rock.
I also try to do reoperative HH via the laparoscopic approach because of the higher morbidity associated with the open approach.
I perform redo surgery by laparoscope at first. If it is indicated you can convert to open procedure. The most important for conversion is the preemptive conversion (not reactive). Type of procedure is depending on the reason of reoperation. For dysphagia convert the previous Nissen to Toupet and using Bougie for calibration. Check the reconstructed (hiatal) are if it is too tight solve the sutures (1 or 2) and use a mesh in onlay position. In cases with inflammatory avoid using of mesh. Recurrent hernia indicates an extended paraesophageal high preparation. Leghtening procedure's indication is rare. Choose a Collis gastroplasty. You can do it laparoscopically too. In patients with recurrent large, giant hernia perform a gastropexy also and reinforce a mesh.
Recurrence/failure is usually a technical issue.Redolap repair either complete or partial repair with mesh deployment at the hiatus is the proceedure of choice.esophageal lengthening is rarely required.ofcourse revision surgeries should be done by an experienced surgeon.
Laparoscopic surgery possible most of the time. Of course conversion is a possibility but the views are better laparoscopically. The indications for re-do surgery need to be catefully considered
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