Modified Management of Giant Hiatal Hernia: Laparoscopic Hiatoplasty With Sac Excision and PosteriorMediastinal Drainage

BACKGROUND: The standard laparoscopic hiatoplasty with Toupet fundoplication is widely regarded as a safe treatment for giant hiatal hernia; however, it is often associated with a high incidence of posterior mediastinal seroma. To address this issue, a modified approach combining sac excision and negative pressure posterior mediastinal drainage has recently been introduced. This study compares clinical outcomes between the conventional and modified techniques to identify the optimal surgical strategy for managing giant hiatal hernia. METHODS: Patients who underwent laparoscopic hiatoplasty with sac excision and posterior mediastinal drainage between January 2013 and September 2020 were included. Demographic information, operative time, intraoperative blood loss, complication rates, length of hospital stay, and treatment outcomes were prospectively collected and assessed during follow-up. RESULTS: A total of 68 patients with giant hiatal hernia underwent the modified procedure without any conversions to open surgery or intraoperative complications. Compared with a historical cohort of 66 patients treated with the conventional approach (laparoscopic hiatoplasty with Toupet fundoplication), the modified group had significantly lower rates of postoperative posterior mediastinal seroma, as well as shorter overall and postoperative hospital stays. No significant differences were observed between the 2 groups regarding operative time, blood loss, ICU transfers, or incidence of postoperative pulmonary atelectasis. Median duration of long-term follow-up was comparable between the groups. There were no significant differences in the rates of early satiety, anatomic recurrence, diarrhea, acid regurgitation, or proton pump inhibitor (PPI) usage. In addition, no cases of dysphagia or reoperation occurred in either group. CONCLUSIONS: Laparoscopic hiatoplasty with sac excision and posterior mediastinal drainage is a safe and effective minimally invasive technique for treating giant hiatal hernia. This approach significantly reduces the risk of mediastinal seroma without increasing complication rates.