A narrative review and single-center experience of secondary hiatal hernia after congenital diaphragmatic hernia repair

Background Gastroesophageal reflux disease (GERD) is the most common long-term gastrointestinal complication among patients after congenital diaphragmatic hernia (CDH) repair. However, increasing evidence suggests some reflux symptoms after CDH repair surgery may be attributed to an underrecognized structural abnormality—secondary hiatal hernia. Secondary HH is an acquired postoperative herniation of abdominal viscera through an enlarged esophageal hiatus. Because secondary HH is defined by anatomic displacement rather than functional impairment, diagnosis relies on imaging, standardized surveillance and management strategies remain lacking. Objective This narrative review synthesizes current evidence regarding the incidence, pathophysiology, clinical strategies, imaging modalities and surgical management of secondary HH following CDH repair, incorporating illustrative institutional observations. Main findings Secondary HH is recognized as a clinically relevant complication following CDH repair. Its development may be associated with mechanisms including diaphragmatic structural abnormalities, tension redistribution, and increased intra-abdominal pressure. Patients often present with GERD symptoms, but a substantial proportion of patients remain asymptomatic. This leads to frequent misdiagnosis or underrecognition of HH cases, which may delay detection and highlights the value of imaging evaluation. Though high-resolution esophageal manometry (HRM) and endoscopy provide much diagnostic information in selected patients, upper gastrointestinal series (UGI) remains a practical imaging modality for structural evaluation. Treatment strategies remain non-standardized but typically involve surgical repair combined with anti-reflux procedures. The choice of surgical approach and patch use remain debated. Our limited institutional experience with five patients shares the diagnostic and surgical information associated with secondary HH in CDH patients. Conclusion Secondary HH represents an underrecognized but clinically significant complication increasingly recognized after CDH repair. Imaging evaluation plays an important role in timely detection. Greater awareness and individualized follow-up strategies may facilitate earlier recognition in selected patients. Further studies are needed to clarify optimal surveillance protocols and management approaches.