The research was conducted at the Department of General Surgery No. 2 of O.O. Bohomolets National Medical University from 2017 to 2023, and at the Kyiv City Clinical Hospital No. 17 from 2017 to 2023.
Hiatal hernia (HH) is a relatively common condition. Some clinical assessments indicate that about 50-60% of patients over the age of 50 suffer from HH, with 5% to 29% of those cases being paraesophageal hernias (PEH) [35, 98].
Preoperative diagnosis of HH, including PEH, is quite challenging, with a wide variety of clinical manifestations. Paraclinical diagnostic methods have relatively low sensitivity and specificity: barium sulfate radiographic examination – 0.63 and 0.85; endoscopic examination – 0.72 and 0.80; and high-resolution manometry – 0.77 and 0.92, respectively [129].
Traditionally, hiatal hernias (HH) are classified into type I (axial or sliding hernias), which are characterized by the displacement of the gastroesophageal junction (GEJ) and the cardiac part of the stomach above the diaphragm by at least 2 cm, while other parts of the stomach remain below the diaphragm [69], and paraesophageal hernias (PEH) (types II-IV). Diagnostic criteria for type II hernias (where the fundus of the stomach herniates into the mediastinum, but the GEJ remains in its normal position) and type IV hernias (where organs other than the stomach are present in the hernia sac) are well-defined [98, 113, 124], while the characteristics of type III hernias (a combination of types I and II) are less clearly defined.
The combination of features from both type I and type II hernias in patients with type III hernias, whose clinical and instrumental manifestations differ, creates challenges in interpreting diagnostic and treatment results [116]. Some authors believe that type III hernias precede type II hernias [108, 154, 173], while others suggest that type III hernias can develop from either type II or type I [169]. However, diagnostic criteria for the origin of type III hernias are currently lacking.
Due to the high recurrence rate in the long-term postoperative period, ranging from 15% to 66%, with an average follow-up period of 12 to 40 months [16, 59, 64, 89, 105, 134, 135, 139, 156, 171], the debate continues on the optimal method for closing the hernia defect—whether it should be suture cruroplasty alone or suture cruroplasty with mesh reinforcement. Both techniques have their advantages. There are opinions supporting a compromise approach to hiatal hernia repair, which involves mesh reinforcement of the sutures for certain defect sizes [83, 86, 117].
However, there is no universally accepted method for measuring the hiatal surface area (HSA) at present. Intraoperative methods (such as determining the sector of a circle [83], or the area of a rhombus or ellipse [38, 102]) do not account for the complex configuration of the HSA. Calculating the HSA using MSCT shows significantly larger average measurements than intraoperative assessments [112, 126, 193], for reasons that are not yet fully understood. In light of this, there is an urgent need to develop a simple and accurate intraoperative (laparoscopic) method for calculating HSA parameters, which is key for choosing the optimal surgical strategy.
An essential aspect of surgical treatment for paraesophageal hernias (PEH) is the performance of fundoplication. Some authors advocate for using Nissen fundoplication at 360° for all patients with PEH to ensure the reduction of GERD symptoms [157, 167]. However, in the long-term postoperative period, this method is associated with the appearance of new symptoms: inability to burp (25.1%), early satiety (29.3%), an increase in the percentage of patients with flatulence from 23.3% to 38.1%, and a high incidence of dysphagia (25.6%) [138]. An alternative to Nissen fundoplication is Toupet fundoplication at 270° [97, 207], which is associated with a lower incidence of obstructive complications and improved quality of life, although it does not offer the same antireflux capability as Nissen fundoplication [14]. At the same time, the criteria for selecting the method of fundoplication remain unclear.
