LAUSR

BACKGROUND Recurrence after hiatal hernia repair is common. The causes are uncertain. Our observation is the site of recurrence is primarily the non-sutured or non-reinforced anterior-left lateral portion of the hiatus. Our aim was to assess the distribution of hiatal hernia recurrence location as a basis for developing a theory of recurrence. METHODS Consecutive patients who underwent repair of recurrent hiatal hernias from 3/2012 to 12/2019 were reviewed. Data gleaned included age, sex, date of operation, location of hiatal hernia recurrence, operative approach, method of hiatal hernia repair, fundoplication performed, need for gastrectomy, and additional procedures. RESULTS 108 consecutive patients were studied. The distribution of recurrence locations: anterior 67%, posterior 12%, and circumferential 21%. Foreshortened esophagus was a contributing factor in 12%. The median time (with interquartile range) in years from the original repair to recurrence was 1.5 (0.9 - 3.75) years for posterior recurrences, 2.75 (1.15- 8.5) years for circumferential recurrences, and 3.25 (1.38 - 10) years for anterior recurrences. Recurrences were repaired in a variety of techniques depending on the clinical circumstances. CONCLUSION Hiatal hernia recurrences due to failure of the crural closure were less common, but early recurrences. The majority of recurrences were due to stretching of the hiatus anterior and to the left of the esophagus. We theorize that the pathophysiology of late hiatal hernia recurrence is widening of the anterior and left lateral portion of the hiatus secondary to repeated stress from differential pressures that eventually overcomes the tensile strength of the hiatus.