Intraoperative FLIP to guide revisional hiatal hernia repair: early experience and outcomes

Abstract Background Revisional hiatal hernia repair (rHHR) represents a challenge in foregut surgery, given scarring, distorted anatomy, and high risk of morbidity. Traditional methods of intraoperative assessment, such as bougie calibration and endoscopic inspection, are subjective and lack physiologic correlation. The functional luminal imaging probe (FLIP) offers objective, real-time assessment of esophagogastric junction (EGJ) diameter, distensibility, and cross-sectional area. This study evaluates the utility of intraoperative FLIP to guide surgical decision-making and assess outcomes in a cohort of complex patients undergoing rHHR. Methods A retrospective review was conducted evaluating patients who underwent FLIP-guided rHHR from 2020 to 2025 at an urban safety-net hospital. Intraoperative FLIP measurements, specifically the diameter (D) and distensibility index (DI), were used to tailor surgical management, including decisions to take down, preserve, or alter the fundoplication. Longitudinal follow-up assessed symptom resolution and quality of life (QOL) using the GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire. Results A total of 17 patients undergoing 18 revisional operations were analyzed (mean age 47.5 years; 88% female). Intraoperative FLIP values prompted a change in surgical management in 61% (11/18) of cases. Modifications included preservation of prior fundoplication (36%), tightening an existing fundoplication (27%), deferral of fundoplication (27%), and changing fundoplication type (9%). At a mean follow-up of 24.9 months, GERD-HRQL scores improved from 26.7 ± 8.5 preoperatively to 16.5 ± 12.9 postoperatively ( p = 0.034). At long-term follow-up (mean 38.8 months), persistent symptoms were noted, including reflux requiring medication (70.6%) and dysphagia (35.3%), though 64.7% of symptomatic patients were managed nonoperatively. Conclusions FLIP-guided revisional HHR facilitates a tailored surgical approach, prompting alterations in management based on objective physiologic data. While clinically meaningful improvements in quality of life were observed, the persistence of symptoms in this high-risk population highlights the intrinsic complexity of revisional foregut surgery and the need for future prospective studies.