Laparoscopic Type IV Hiatal Hernia Repair in the Elective and Emergency Settings, Clinical Presentation, Outcomes, and Same-Day Surgery in Elective Repairs

Objective: We aimed to compare the outcomes of laparoscopic type IV hiatal hernia repairs in elective and emergent settings and assess the feasibility of same-day surgery (SDS) in elective repairs. Methods: SDS was defined as discharge on the day of the procedure. The feasibility of SDS in elective repairs was assessed. Results: There were 265 primary type IV hernia repairs: 208/265 (78.5%) elective versus 57/265 (21.5%) in emergent settings, age:70.0 (64.0-75.0) versus 73.0 (60.8-82.0), P = .059, BMI: 30.1 (26.6-33.8) versus 27.5 (24.4-32.4), P = .025, ASA IV: 5/208 (2.4%) versus 11/57 (19.3%), P < .001, LOS:1 (0-2) versus 2 (1-4), P < .001, 30-day mortality: 0/208 (0.0%) versus 2/57 (3.5%), P = .046. SDS was planned in 83/208 (39.9%) elective procedures and performed in 65/83 (78.3%); 18/83 (21.7%) were transitioned from SDS to observation/inpatient. NGT was attempted in 18/57 (31.6%) in emergent setting and was successful in 5/5 at the bedside and 11/13 (84.6%) endoscopically. Ischemia was seen in 4/57 (7.0%) in emergent settings and perforation in 1/4. Time from surgical consultation to arrival to the OR in patients without ischemia/perforation/obstructive gastric volvulus (n = 50) was 57.9 hours (44.0-79.7) versus 5.5 hours (4.1-8.9) in those with, (n = 7). Conclusion: Type IV hiatal hernia can be repaired laparoscopically with good outcomes in elective and emergent settings and as SDS in elective repairs. Emergent presentations can occur in about 20% of type IV hernias in older patients with lower BMI and higher ASA. Ischemia/perforation are rare. Emergent presentations without ischemia/perforation can be treated with gastric decompression and urgent repair during the same admission.