Operative Repair of Hiatal Hernias

Laparoscopic hiatal hernia repair is now considered the standard of care despite the lack of level 1 evidence  to support its use.
Port placement: 
- 10mm umbo camera port
- 10 mm epigastric liver retraction port
- 5mm para-rectus operating ports
- 5mm R ant axill line fundal retraction port

- Description of procedure ...

Controversies:

- Fundoplication? Accepted for type 1 and 3 as they usually have significant reflux symptoms.  Less clear for type 2 .  Technically GE jxn is in abdomen - however, these patients may have subclinical symptoms of reflux.  In general, addition of reflux procedure well accepted because it helps anchor the stomach in the abdomen to prevent hernia recurrence and type 2 pts may have subclinical sx that are unmasked by repair of hernia.

- Use of mesh: not of proven benefit, however with advent of surgisis mesh, risks associated with non-absorbable mesh averted and generally used now.