Guidelines for the management of hiatal hernia

Preamble

The guidelines for the management of hiatal hernia are a series of systematically developed statements to assist physicians’ and patients’ decisions about the appropriate use of laparoscopic surgery for hiatal hernia. The statements included in this guideline are the product of a systematic review of published literature on the topic, and the recommendations are explicitly linked to the supporting evidence. The strengths and weaknesses of the available evidence are highlighted and expert opinion sought where the evidence is lacking.

Disclaimer

Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when few or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests. They are intended to indicate the preferable, but not necessarily the only, acceptable approaches, given the complexity of the health care environment. Guidelines are intended to be flexible. As a result of the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.

Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed, and revised by the Guidelines Committee, then reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production on the basis of the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research, knowledge, and practice.

Literature review methodology

A large body of literature exists on the management of hiatal hernia. A systematic literature search was performed on PubMed in February 2011. A further search directed toward the pediatric literature was performed in February 2013. The search strategies were limited to human articles and are shown in Table 3 in Appendix 1.

A total of 392 relevant articles in the past 5 years were identified. The pediatric-specific search yielded 52 articles. The abstracts were reviewed and divided into the following categories: randomized studies, meta-analyses, and systematic reviews; prospective studies; retrospective studies; case reports; and review articles.

Randomized controlled trials (RCTs), meta-analyses, and systematic reviews were selected for further review, along with prospective and retrospective studies that included at least 20 patients. Studies with smaller samples were considered when additional evidence was lacking and if a specific point was highlighted. The most recent reviews were also included. All case reports, older reviews, and smaller studies were excluded. According to these exclusion criteria, 153 articles were reviewed. A further 15 references were included in the pediatric-specific search. Whenever the available evidence from high-quality studies was considered to be adequate, lower-evidence level studies were not considered. Duplicate publications were considered only once.

The reviewers graded the level of evidence and manually searched the bibliography of each article for additional articles that may have been missed during the original search. This stage of the search continued to November 2011. The additional relevant articles (n = 96) found were also included in the review. A total of 248 graded articles relevant to this guideline were reviewed. To facilitate review by multiple reviewers, these articles were divided into the following topics:

• (a) Definitions, classification, and pathophysiology.

• (b) Diagnosis.

• (c) Natural history and indications for surgery.

• (d) Preoperative assessment.

• (e) Technical considerations.

  • i. Transthoracic versus transabdominal.

  • ii. Hernia sac excision versus simple reduction.

  • iii. Laparoscopic versus open.

  • iv. Mesh cruroplasty versus no reinforcement.

  • v. Fundoplication versus no antireflux procedure.

  • vi. Gastropexy versus no gastric fixation.

• (f) Outcome.

• (g) Predictors of success.

• (h) Revisional surgery.

• (i) Pediatric considerations.

Both the quality of the evidence and the strength of the recommendation for each of the below guidelines was assessed according to the GRADE system [1] described in Table 4 in Appendix 1. There is a 4-tiered system for quality of evidence, as follows: very low (⊕), low (⊕⊕), moderate (⊕⊕⊕), or high (⊕⊕⊕⊕). There is a 2-tiered system for strength of recommendation: weak or strong. Further definitions are provided by SAGES elsewhere [2]. Where current literature does not support a conclusion, the opinion of experts in the field is offered so informed management decisions can be made.

Limitations of the available literature

Despite the availability of several RCTs and meta-analyses, most available studies are either prospective or retrospective reports. Several limitations exist in the examined literature. First, the general methodological quality of the available trials is low as a result of small patient numbers, inadequate trial design or methodology, lack of standardization, and lack of objective outcome assessment [1]. Only a few studies report a power analysis and define a main outcome variable. Thus, the validity of several of the pooled analyses of the available meta-analyses is hampered by statistically significant heterogeneity related to small sample size. In addition, the reporting of outcomes varies significantly, as does the follow-up period, making it difficult to combine and compare such data. Furthermore, there are several differences in the surgical technique used that may directly affect the outcomes of interest and introduce bias into the reported outcomes. Much of the literature regarding the management of hiatal hernias refers only to certain subtypes; other subtypes, particularly large symptomatic sliding type I hernias, are often overlooked yet require coverage by these guidelines. Finally, the majority of the studies do not report details on the expertise of their surgeons, and most studies were conducted in single institutions, making generalization of their findings difficult.

Introduction to hiatal hernia

Hiatal hernia is a common disorder [3, 4]. It is characterized by a protrusion of any abdominal structure other than the esophagus into the thoracic cavity through a widening of the hiatus of the diaphragm.

Definitions and etiology

Attempts began early in the last century to classify hiatal hernia into subtypes [5]. The current anatomic classification has evolved to include a categorization of hiatal hernias into types I through IV.

• 1. Type I hernias are sliding hiatal hernias, where the gastroesophageal junction migrates above the diaphragm [6]. The stomach remains in its usual longitudinal alignment [7] and the fundus remains below the gastroesophageal junction.

• 2. Type II hernias are pure paraesophageal hernias (PEH); the gastroesophageal junction remains in its normal anatomic position, but a portion of the fundus herniates through the diaphragmatic hiatus adjacent to the esophagus.

• 3. Type III hernias are a combination of types I and II, with both the gastroesophageal junction and the fundus herniating through the hiatus. The fundus lies above the gastroesophageal junction.

• 4. Type IV hiatal hernias are characterized by the presence of a structure other than stomach, such as the omentum, colon, or small bowel within the hernia sac.

More than 95 % of hiatal hernias are type I. Types II to IV as a group are referred to as PEH and are differentiated from type I hernias by relative preservation of posterolateral phrenoesophageal attachments around the gastroesophageal junction [8]. Of the PEH, more than 90 % are type III, and the least common is type II [7]. The term “giant paraesophageal hernia” appears frequently in the literature, although its definition is inconsistent. Various authors have suggested that giant PEH be defined as all type III and IV hernias [9], but most limit this term to PEH having more than a third to half of the stomach in the chest [10–12].

These guidelines are specific for each type of hiatal hernia because the implications of a hiatal hernia and the indications for repair differ between the sliding (type I) hernias and for the PEH (types II, III, and IV).

Cephalad migration of the gastroesophageal junction may result from weakening of the phrenoesophageal ligament. Depletion of elastin fibers leads to stretching of the ligament and proximal displacement of the gastroesophageal junction [13]. Most cases of hiatal hernia are acquired rather than congenital, although familial clustering has been reported, and in a very small number of cases, multifactorial inheritance may play a part [14].

Other diaphragmatic hernias exist but are not included in this review. These include acquired hernias such as traumatic diaphragmatic hernias; the rare parahiatal hernias in which the hernia defect arises lateral to the crural musculature and not through the esophageal hiatus itself; iatrogenic diaphragmatic hernias, such as those that misguided chest tubes or after thoracoabdominal incisions in which the diaphragm is taken down [7]; and congenital diaphragmatic defects such as posterolateral Bochdalek hernias and retrosternal Morgagni hernias.

Recurrent hiatal hernias are included in this review. Some authors advocate that any hernia observed via postoperative radiological contrast imaging or on gastroscopy is classified as a recurrence [15, 16]. Other authors limit the definition of recurrence to those greater than 2 cm in length [17]. Importantly, most reports indicate that small recurrences are seldom clinically significant [18].

Gastric volvulus is a rare condition characterized by pathological rotation of the stomach, most commonly associated with paraesophageal hiatal hernias. Gastric volvulus can occur in the abdomen or in the chest and can be classified according to the axis of rotation, organoaxial and mesenteroaxial. Organoaxial is the most common type, with rotation occurring about the long axis of the stomach connecting the gastroesophageal junction to the pylorus. Mesenteroaxial, with rotation about the short axis of the stomach, bisecting the lesser and greater curvature, is less common. A combination of the two may exist. Primary gastric volvulus has no causative condition, but the more common secondary gastric volvulus is associated with underlying conditions such as PEH, connective tissue disorders, and anterior abdominal wall defects. Although gastric volvulus has been reported in all ages, it is more often diagnosed in elderly patients. Hiatal hernia with intrathoracic acute gastric volvulus usually presents with progressive chest pain, severe vomiting, and epigastric distention. The classical Borchardt triad, which comprises severe epigastric pain, unproductive retching, and inability to pass a nasogastric tube, represent total gastric obstruction [19].

Diagnosis

Guideline 1

Hiatal hernia can be diagnosed by various modalities. Only investigations that will alter the clinical management of the patient should be performed (⊕⊕⊕, strong).

The diagnostic pathway for sliding hiatal hernias overlaps with that of gastroesophageal reflux disease (GERD) (Fig. 1). Diagnosis of hiatal hernias is described in this document. Diagnosis of GERD has been described in a previous SAGES publication [20].

Fig. 1

Diagnostic pathway for GERD and for hiatal hernia

Plain chest radiographs may identify soft tissue opacity with or without an air fluid level within the chest. A retrocardiac air fluid level on chest X-ray is pathognomonic for a paraesophageal hiatal hernia. Visceral gas may be seen in cases of intestinal herniation. Also, loops of bowel may be visualized running in an unusual vertical pattern toward the sac, and a characteristic displacement or upward deformity of the transverse colon may be seen in cases of colon herniation [21].

Contrast studies are helpful to gauge the size and reducibility of the hiatal hernia and to localize precisely the gastroesophageal junction in relation to the esophageal hiatus. Contrast findings may add to suspicion of existing short esophagus [22]. This may allow the surgeon to be prepared to address a short esophagus with a lengthening procedure if needed intraoperatively. Further, when performed as a video esophagram, information on bolus transport is provided by the study. Barium is the contrast agent most frequently reported in the literature as used for this purpose. Given the increased aspiration risk of patients with PEH presenting with acute gastric outlet obstruction, ionic water soluble contrast should be generally avoided because of the risk of aspiration pneumonitis [23].

Computed tomography (CT) scan may be useful in an urgent situation for patients with suspected complications from a volvulized PEH. The hernia site and any herniated organs within the chest cavity are clearly visualized in most cases. Multislice CT with sagittal, coronal, and 3D reformatted images has increased the sensitivity of CT for the detection of hiatal hernia [24]. If intestinal obstruction and strangulation occur, dilated intestinal segments will be visualized with air fluid levels within the chest cavity and abdomen. Cephalad migration of the gastroesophageal junction or gastric fundus through the hiatus can be clearly visualized on oral contrast–enhanced CT images.

Esophagogastroduodenoscopy (EGD) allows for visual assessment of the mucosa of the esophagus, stomach, and duodenum. The presence of erosive esophagitis or Barrett esophagus can be determined. Further, the size and type of hernia can be determined. Inability or difficulty reaching the duodenum in the presence of a large hiatal hernia is diagnostic of a volvulized PEH. Evaluation of gastric viability is particularly important among patients undergoing emergency surgery for incarcerated hernias.

Esophageal manometry can demonstrate the level of the diaphragmatic crura, the respiratory inversion point, and the location of the lower esophageal sphincter. The size of the sliding component of a hiatal hernia can then be calculated, particularly with new high-resolution motility technology. In patients with a paraesophageal hiatal hernia, placement of the manometry catheter across the lower esophageal sphincter and below the diaphragm can be difficult [25, 26]. Expert opinion suggests that contrast swallow showing normal motility may replace the need for a catheter-based manometry study in patients with a paraesophageal hiatal hernia. However, an esophageal motility study is critical to enable a pH probe to be properly positioned above the lower esophageal sphincter in patients with a sliding hiatal hernia and symptoms of gastroesophageal reflux.

pH testing has limited relevance in the diagnosis of a hiatal hernia, but it is critical to identify the presence of increased esophageal acid exposure in patients with sliding hiatal hernias that might benefit from antireflux surgery. Confirmation of abnormal gastroesophageal reflux either by the identification of erosive esophagitis or Barrett esophagus on upper endoscopy, or by demonstration of increased esophageal acid exposure on pH monitoring is necessary before consideration of operative intervention in patients with a sliding hiatal hernia.

Nuclear medicine studies [27], transesophageal echocardiogram [28], and endoscopic ultrasound can also demonstrate hiatal hernias but are not routinely used for diagnosis.

The mainstays of evaluation for patients with a hiatal hernia, particularly before operative intervention, are upper endoscopy and barium swallow. Contrast studies are reported to be more sensitive than endoscopy in detecting sliding hiatal hernia, at least in the bariatric population [29]. The role of the various diagnostic techniques may depend on the clinical presentation of the patient. Incidentally detected hiatal hernias or those hernias that are minimally symptomatic may be assessed by endoscopy and contrast radiology. A CT scan can be performed if additional information is needed to aid in further clinical decision making. Findings of a stomach in an unusually high position or with an abnormal axis in a patient with acute abdominal pain and vomiting should make one suspect gastric volvulus [30]. Emergency presentations of hiatal hernia, such as with gastric obstruction or ischemia, may first be decompressed with a nasogastric tube followed by a plain chest radiograph and endoscopy. Excessive investigation in emergency presentation may lead to delay in treatment and suboptimal outcomes [31]. CT scan may be especially useful in cases of diagnostic dilemma, although in retrospect, the diagnosis is frequently evident on prior imaging [32].

Indications for surgery

Guideline 2

Repair of a type I hernia in the absence of reflux disease is not necessary (⊕⊕⊕, strong).

The major clinical significance of a type I hernia is its association with reflux disease. In patients with proven GERD, with or without a sliding hiatal hernia, antireflux surgery is an option for the management of their condition [33, 34]. The indication for repair of a sliding (type I) hiatal hernia is GERD. The hernia is not the indication for the procedure but must be repaired. A fundoplication to address the reflux disease is mandatory [20]. Outside of this situation, type I sliding hiatal hernias have been thought to be almost inconsequential and not warranting of themselves surgical repair [35], despite a few studies reporting severe symptoms and complications related to these hernias [36–38]. Occasionally such hernias are thought to produce dysphagia symptoms or rarely gastric ulceration. Although these may occur, they are rare, and repair of a type I hernia is nearly always unnecessary in the absence of GERD.

Guideline 3

All symptomatic paraesophageal hiatal hernias should be repaired, particularly those with acute obstructive symptoms or those that have undergone volvulus (⊕⊕⊕⊕ , strong).

Guideline 4

Routine elective repair of completely asymptomatic PEH may not always be indicated. Consideration for surgery should include the patient’s age and comorbidities (⊕⊕⊕, weak).

Guideline 5

Acute gastric volvulus requires reduction of the stomach with limited resection if needed (⊕⊕⊕⊕, strong).

Many patients with a hiatal hernia are symptomatic [10]. However, for many patients, these symptoms are only mild, and the condition is detected incidentally on a chest radiograph performed for another reason [8, 39]. In patients with sliding hiatal hernias, symptoms are generally attributable to gastroesophageal reflux. Expert opinion suggests that truly asymptomatic paraesophageal hiatal hernias do exist but are rare. When the patient is questioned carefully, he or she often mentions symptoms such as postprandial chest fullness or shortness of breath. Heartburn and reflux symptoms are uncommon with PEH.

It is likely that some paraesophageal hiatal hernias develop from smaller hiatal hernias. Others may develop from anatomic changes, such as those occur with kyphosis and degenerative disc disease in the spine [40]. As more stomach moves up into the thorax, respiratory symptoms may predominate as a result of pulmonary compression and reduction in forced vital capacity [10, 41]. Recurrent aspiration pneumonia is also possible [39]. Later, with vascular compromise from volvulus, gastric mucosal ischemia may cause ulceration, bleeding, and anemia. Iron deficiency anemia can be seen in up to 50 % of patients with a paraesophageal hiatal hernia [41].

Obstructive symptoms range from mild nausea, bloating, or postprandial fullness to acute distress with dysphagia and retching. Pain, often described as a full or heavy feeling in the upper abdomen or as severe postprandial pain, is often relieved by vomiting [42]. Dysphagia and postprandial fullness occur as a result of compression of the adjacent esophagus by a progressively expanding herniated stomach and by angulation of the gastroesophageal junction that occurs as the stomach becomes progressively displaced in the chest, and also by volvulus of the stomach as that organ migrates progressively into the chest [43].

Very little published information exists regarding the natural course of untreated hiatal hernias. Of the few data available, most articles describe hernias thought to be at risk of developing acute symptoms, particularly obstruction. Only hernias where the gastric fundus has migrated above the diaphragm—that is, PEH—are at risk of obstruction. There is a suggestion that the risk of progression from asymptomatic to symptomatic PEH is approximately 14 % per year [44, 45]. This information, together with early reports of near-universal mortality resulting from these complications, particularly from gastric necrosis, has in the past led to the dictum that all PEH should be repaired electively in suitable surgical candidates [46, 47]. This is particularly important for patients with symptomatic hernias where the risk of complication is said to be higher [48]. Age should not be a barrier to repair of symptomatic hernias [49]. However, more recent reports have shown that mortality rates for emergency PEH operations are currently much lower than those reported in the last century [50, 51]. Mortality rates for emergency repair have been reported to be as low as 0–5.4 % [45, 52], although average mortality rates for emergency hiatal hernia surgery are around 17 % [45]. Moreover, the risk of developing acute symptoms requiring emergency surgery is probably less than 2 % per year [45, 53–56].

Decision analysis modeling of contemporary data suggests that routine elective repair of completely asymptomatic PEH may not be indicated [45]; that is, such hernias may be safe to observe and to manage expectantly. This conclusion, which is based on analysis of five studies [53–57], suggests that repair should be reserved for patients with symptoms of gastric outlet obstruction, those with severe gastroesophageal reflux or anemia, and those with possible gastric strangulation. Furthermore, this model suggested that elective laparoscopic hiatal hernia repair in asymptomatic patients might actually decrease the quality-adjusted life expectancy for patients aged 65 years and older. Surgical repair of hernias for the aforementioned respiratory symptoms and symptoms of postprandial fullness is less well studied.

Strangulation of the stomach can be a consequence of acute gastric volvulus, with resultant ischemia, necrosis, and perforation of the stomach. Treatment includes reduction of the stomach and limited gastric resection in cases of gastric necrosis. The laparoscopic approach can be used in the majority of cases, but conversion to an open procedure should be considered for complex problems or when appropriate for the safety of the patient [58, 59].

Repair of hiatal hernia during bariatric operations

Guideline 6

During operations for Roux-en-Y gastric bypass, sleeve gastrectomy, and the placement of adjustable gastric bands, all detected hiatal hernias should be repaired (⊕⊕⊕, weak).

Hiatal hernias are often detected during the course of a bariatric operation or other operations at or near the diaphragmatic hiatus. The hernias can be detected by noting “dimpling” anterior to the esophagus or by noting a large hernia sac with contents. Some describe the disappearance with gentle traction of the inflated band calibration balloon up into the mediastinum as being evidence of a hiatal hernia. There are many references in the literature of increased complications, particularly heartburn, after placement of an adjustable gastric band in patients with a hiatal hernia [60–62], although these data are neither prospectively collected nor controlled. Because of this association with gastroesophageal reflux symptoms, many now recommend looking for and repairing hiatal hernias at the time of gastric band insertion [61, 63]. This advice must be tempered by other reports that show that placement of an adjustable gastric band may relieve reflux symptoms, even without reduction of a hiatal hernia [64, 65].

In a retrospective study of patients undergoing adjustable gastric band placement [66], all sliding hiatal hernias identified intraoperatively were repaired by posterior crural approximation. If a hernia was not evident but there was nonetheless dimpling anterior to the esophagus, then an anterior crural approximating stitch was placed. This study demonstrated a significant reduction in reoperation rates for band prolapse and pouch dilatation when this approach was implemented. The authors concluded that repairing any detected hiatal hernia during band placement is to be recommended [61].

There are small case series suggesting possible benefits of hiatal hernia repair combined with other types of bariatric surgery, such as gastric bypass [67–69] and sleeve gastrectomy [70–72].

Predictors of outcome

Guideline 7

Postoperative nausea and vomiting should be treated aggressively to minimize poor outcomes (⊕⊕, strong).

In the early postoperative period, sudden increases in intra-abdominal pressure are thought to predispose to anatomical failure. Also, early postoperative gagging, belching, and vomiting have been suggested to be predisposing factors for anatomical failure and the need for revision [73].

Morbidity is substantially higher among elderly patients and those with comorbidities when compared to younger patients, but with no increase in the recurrence rate. Mortality rate among elderly patients undergoing PEH repair continues to be high after emergency procedures [74]. The mortality is related mainly to pulmonary complications, thromboembolic events, and hemorrhage [75].

Obesity, a significant independent risk factor for development of a hiatal hernia [76], also increases the rate of hernia recurrence [77, 78].

The larger the size of the hiatal hernia, as measured by the hiatal surface area, the more likely the recurrence [79], particularly if the surface area is greater than 5.6 cm² independent of patient height, weight, and body mass index [80]. Some authors suggest using mesh crural reinforcement for these large hernias to prevent recurrence [81].

Technical considerations of operative approach—transthoracic or transabdominal; laparoscopic or open

Guideline 8

Hiatal hernias can effectively be repaired by a transabdominal or transthoracic approach (⊕⊕⊕⊕, strong). The morbidity of a laparoscopic approach is markedly less than that of an open approach (⊕⊕, strong).

Guideline 9

Laparoscopic hiatal hernia repair is as effective as open transabdominal repair, with a reduced rate of perioperative morbidity and with shorter hospital stays. It is the preferred approach for the majority of hiatal hernias (⊕⊕⊕⊕, strong).

Large hiatal hernias can be repaired either transabdominally (open or laparoscopic) or via thoracotomy [82], usually through the left chest. There are no randomized trials directly comparing open transthoracic versus open transabdominal hiatal hernia repair, and there are no data assessing minimally invasive thoracic approaches. There is decreased perioperative morbidity and mortality with laparoscopic repair compared to open transthoracic repair [83, 84]. Although the transthoracic approach offers excellent visualization of the hiatus and the ability to maximally mobilize the esophagus, expert opinion suggests that the morbidity and prolonged recovery associated with this approach have rendered it obsolete except in rare circumstances. Nonetheless, one potential advantage of the transthoracic route is the ability for more extensive esophageal mobilization [85]. However, many transthoracic series have a higher percentage of patients requiring Collis gastroplasty compared to laparoscopic series [86]. The standard for repair today is a laparoscopic approach. Critics of the laparoscopic series cite false overestimation of intra-abdominal esophageal length due to diaphragmatic elevation from pneumoperitoneum [87] as a limitation of the approach. Further, the complexity of a laparoscopic Collis gastroplasty prohibits its use in some cases. Transabdominal open repair may be most appropriate in an emergency where there is peritoneal contamination or gastric necrosis [52].

Geha et al. [88] reported follow-up for 100 consecutive patients undergoing open repair. In their experience in 18 patients who underwent transthoracic repair, two patients required subsequent transabdominal repair for organoaxial volvulus. In the remaining patients, a transabdominal repair was done with frequent use of gastropexy. Fundoplication was done only selectively and Collis gastroplasty done only in 2 % of the patients. There were no recurrences in the entire cohort. Other contemporary authors have compared transabdominal to transthoracic access for PEH repair and have concluded that outcomes are equivalent [89].

Laparoscopic hiatal hernia repair results in less postoperative pain compared with the open approach. The smaller incisions of minimally invasive surgery are less likely to be complicated by incisional hernias and wound infection. Postoperative respiratory complications are reduced [90]. Results from multiple studies are similar, with shorter hospital stay and less morbidity resulting from the minimally invasive approach [55, 91–101]. Recurrence rates are similar.

Open conversion is occasionally necessary for reasons such as bleeding, splenic injury, or dense adhesions, and it is important that surgeons taking these on as laparoscopic procedures are comfortable with an open repair should conversion become necessary.

Hernia sac excision

Guideline 10

During paraesophageal hiatal hernia repair the hernia sac should be dissected away from mediastinal structures (⊕⊕, strong) and then preferably excised (⊕⊕, weak).

Sac dissection during PEH repair is thought to release the tethering of the esophagus to facilitate intraoperative reduction of the hernia and to decrease early recurrence, as well as to protect the esophagus from iatrogenic damage [95, 102]. Before addressing the sac on the right side of the esophagus, the left gastric vessels should be reduced into the abdomen to prevent injury. Subsequent excision of the peritoneal hernia sac is performed routinely in most recent reports [12, 103], but not all [104]. There is some evidence to support this practice [105], although the single case series examining the issue had marked variation in the type of hiatal hernia and operative technique and was early in the surgeons’ learning curve. Five of 25 operations without sac excision experienced hernia recurrence during a 38-month follow-up period, all between 1 to 8 weeks after surgery. No recurrences were reported at 15 months’ follow-up for the 30 patients whose PEH repair procedure included hernia sac excision. The authors’ conclusion was that sac excision is an “essential” step in laparoscopic PEH repair. Studies examining sac excision that actually specify hernia type fail to include type I hernia.

Occasionally sac excision can be quite difficult, particularly in large hiatal hernias. Some advocate that under this circumstance, disconnection of the sac from the crura and sac dissection only is performed, but sac excision is not required [102, 106]. Sac excision in such circumstances might predispose to vagal injury. When this technique is compared to complete excision in retrospective but underpowered analyses, leaving of the sac in situ results in trends toward higher recurrence, but no statistical difference has been seen [107]. Expert opinion suggests that if the sac is not to be completely excised, then at least partial sac excision should be performed to allow the fundoplication to be performed without excess bulk by a large residual sac.

Reinforced repair

Guideline 11

The use of mesh for reinforcement of large hiatal hernia repairs leads to decreased short term recurrence rates (⊕⊕⊕, strong).

Guideline 12

There are inadequate long-term data on which to base a recommendation either for or against the use of mesh at the hiatus.

Primary sutured crural repair has been the mainstay of practice for many years, but objective follow-up has suggested very high recurrence rates of 42 % and higher after laparoscopic PEH repair [108, 109]. This has prompted many authors to advocate that the crural repair be reinforced. The ideal mesh and technique are unknown at this point. Although some novel hiatal reinforcement techniques have been developed, such as using the ligamentum teres [110] or left lobe of the liver [111] for this purpose, most reinforced repairs use some form of mesh. Most commonly the mesh is applied in an onlay fashion after primary crural closure. A variation, which is similarly considered as a reinforced crural approximation, is the use of pledgets to buttress the primary sutured hiatal repair [112]. In some cases mesh has been used as an interposition or bridge when crural approximation is not possible [113]. In the rare occasion when the crus cannot be primarily approximated, various techniques using native or prosthetic material have been described, as have techniques for crural relaxing incisions to allow primary crural closure in patients with large defects [87, 114–117].

Three RCTs, summarized in Table 1, have examined the question of whether mesh repair is beneficial. The first [118] specifically studied patients with a giant hiatal defect, defined as greater than 8 cm crural separation. The type of hernia was not specified. With a mean follow-up of 3.3 years, radiographic recurrence was 22 % in the primary sutured repair group (all of which occurred within the first 6 months postoperatively) and zero in a group which had onlay polytetrafluoroethylene (PTFE) reinforcement of the crural repair. All recurrences were symptomatic, although the symptoms were not described. The PTFE mesh encircled the esophagus. No mesh-related complications during the study period were reported.

Table 1 Prospective randomized controlled studies evaluating recurrence of PEH after mesh repair

The second RCT [119] did not examine hiatal hernias per se but included patients who underwent full esophageal mobilization at the diaphragmatic hiatus in the course of a fundoplication for GERD. Approximately half of the studied patients had a hernia defect greater than 5 cm. A rectangular piece of polypropylene mesh was placed in onlay fashion over the crural repair. Of patients with a primary repair of the crura, 26 % developed a subsequent hiatal hernia compared to only 8 % of patients receiving the mesh.

The third RCT [17] trial included hernia defects 5 cm or greater and randomized patients to either primary repair or an onlay application of a U-shaped porcine small intestinal submucosal biologic prosthesis. In the control group, 90 % of patients had a type III or IV hernia compared to 84 % of patients in the treatment arm. A significant number of patients were not followed up according to the study protocol. Many interim analyses were performed, and it is unclear whether these analyses were accounted for in either initial sample size determination or interim stopping rules [120]. Radiological recurrences were reported in 24 % (n = 12) of patients with primary repair versus 9 % (n = 4) in the biologic prosthesis group (p = 0.04) at 6 months. No mesh-related complication was reported. Follow-up data from this study have recently been published and reported equal recurrence rates in both arms. At 4 years’ follow-up, there was no improvement in recurrence rates with the use of mesh (both arms showed recurrence rates of >50 %) or in clinical symptoms [121]. There was a significant dropout rate during this follow-up study, and not all patients completing the study underwent radiographic evaluation for recurrence. More patients from the mesh repair group failed to be completely followed up compared to the primary repair control group, introducing an element of bias into the conclusions.

In summary, short-term results of these three RCTs were supportive of reinforced hiatoplasty, but this has not been borne out with longer-term results. Additional evidence is required to better establish the safety and long-term outcomes of mesh use at the hiatus.

Many case series exist on the topic, and the majority suggest benefit with mesh [122–128]. However, a few question the use of mesh repair [129–132].

Extrapolation from the use of mesh in abdominal wall hernias suggests that the use of such products to bridge a defect—that is, to span the crural defect without primary crural approximation—is unlikely to be successful [116, 117, 133].

Long-term safety related to the type of mesh used and placement technique is important, with many similarities being drawn in the literature to the Angelchik prosthesis used as an antireflux barrier in past decades, which was found to cause frequent erosions into the esophageal lumen [134]. A limitation of the available data is the lack of long-term follow-up mesh implantation. Most reports are small case series with a median follow-up of less than 3 years. Complications are reported with all types of mesh, both synthetic and biologic, as well as of varying mesh geometry [131, 132, 135]. Although mesh erosion is the most feared complication [135–137], other complications also can occur, such as esophageal stenosis [132], pericardial tamponade [138], and effusion. Expert opinion suggests that synthetic mesh when placed as a bridge is more likely to have direct contact with the esophagus and as a result is probably associated with erosion. Bridging synthetic mesh should therefore be avoided.

The meshes have been affixed by a variety of different techniques, including various glues, tacks, and sutures [104, 139]. Inadequate evidence exists for a recommendation to be made regarding optimal fixation techniques, although care should be taken that fixation methods (particularly tacks) do not breach the aorta or pericardium when applied low on the left crus or near the apex of the crura anteriorly.

Fundoplication

Guideline 13

A fundoplication must be performed during repair of a sliding type hiatal hernia to address reflux. A fundoplication is also important during PEH repair (⊕⊕, weak).

Guideline 14

In the absence of achalasia, tailoring of the fundoplication to preoperative manometric data may not be necessary (⊕⊕, weak).

The majority of reports of paraesophageal hiatal hernia repair in the recent literature describe the performance of a fundoplication as a step of the repair. This is thought to aid in prevention of postoperative gastroesophageal reflux and to buttress the repair to prevent recurrence [25, 140, 141]. Moreover, there is a suggestion that the majority of patients with PEH have an incompetent lower esophageal sphincter [142]. Extensive hiatal dissection might also potentiate reflux. There is, however, no high-level evidence to support this practice of routine fundoplication; case reports form the majority of the evidence base, and the conclusions are mixed. Two generally representative studies are described as an illustration.

First, one recent case–control study [143] divided 46 patient undergoing laparoscopic paraesophageal hiatal hernia repair into two equal groups with and without fundoplication. The complete 360° fundoplications were performed over a 56F bougie and generally without division of the short gastric vessels. Findings were of increased dysphagia with fundoplication and of reflux symptoms in the group without fundoplication. The authors concluded that routine fundoplication should be avoided.

Second, a separate retrospective study comparing 40 patients undergoing fundoplication for both reflux disease and hiatal hernia showed no dysphagia with fundoplication in the group of patients with PEH [144]. The authors concluded that there exists a benefit in reflux symptoms with the routine use of a fundoplication as an addition to the repair of the hiatus.

Hernia recurrence rates after fundoplication are not satisfactorily addressed in the current body of literature.

There is little information available in the current literature about tailoring the fundoplication during hiatal hernia repair, although preoperative manometric data have been used to guide the degree of wrap [8]. The SAGES Guidelines for surgical treatment of GERD [20] found that a tailored approach to fundoplication is unwarranted in the surgical treatment of reflux, although this document did not examine the case of hiatal hernias.

Short esophagus

Guideline 15

A necessary step of hiatal hernia repair is to return the gastroesophageal junction to an infradiaphragmatic position (⊕⊕⊕, strong).

Guideline 16

At the completion of the hiatal repair, the intra-abdominal esophagus should measure at least 2–3 cm in length to decrease the chance of recurrence (⊕⊕, weak). This length can be achieved by mediastinal dissection of the esophagus and/or gastroplasty (⊕⊕⊕⊕, strong).

Hiatal hernia recurrence can be reduced by extensive mediastinal esophageal mobilization to bring the gastroesophageal junction at least 2–3 cm into the abdomen without tension [10, 22, 145, 146]. High mediastinal dissection may reduce the need for an esophageal lengthening procedure [147]. If mobilization fails to bring the gastroesophageal junction into the abdomen, an esophageal lengthening procedure should be performed [9, 43]. The addition of a Collis gastroplasty is suggested in several studies when a short esophagus is encountered after reduction of the hernia, dissection of the hernia sac, and mobilization in the mediastinum [10, 148]. Some authors report very high utilization rates of Collis gastroplasty for primary hiatal hernia repair, particularly of types III and IV, with some even using this procedure for the majority of patients. These retrospective reviews usually describe low recurrence rates [86, 149]. The gastric neoesophagus formed by a Collis gastroplasty does not exhibit peristaltic activity like the native esophagus, and therefore dysphagia is a potential problem [150]. Also, performance of a gastroplasty increased the rate of postoperative leaks in some studies [151]. There is evidence that a Collis gastroplasty is quite safe to perform if a foreshortened esophagus is encountered, although perioperative complication rates are higher than when a gastroplasty is not performed. Rates of postoperative dysphagia after Collis gastroplasty vary between reports (Table 2).

Table 2 Evaluation of the management of short esophagus

A recent paper describing outcome of 166 patients undergoing either reoperative antireflux surgery or hiatal hernia repair evaluated vagus nerve division in the setting of a short esophagus [152]. It was proposed that a vagotomy is an alternative to Collis gastroplasty when extensive mobilization of the esophagus fails to provide adequate esophageal length. The authors did not find any significant difference between a control group and the vagotomized group in terms of symptoms like abdominal pain, bloating, diarrhea, or early satiety. No patient in this study required subsequent surgical intervention for gastric outlet obstruction. Vagotomy for esophageal lengthening cannot be recommended on the basis of this one study alone.

Gastropexy

Guideline 17

Gastropexy may safely be used in addition to hiatal repair (⊕⊕⊕⊕, strong).

Guideline 18

Gastrostomy tube insertion may facilitate postoperative care in selected patients (⊕⊕, strong).

Guideline 19

Hernia reduction with gastropexy alone and no hiatal repair may be a safe alternative in high-risk patients but may be associated with high recurrence rates (⊕⊕, weak). Formal repair is preferred (⊕⊕⊕⊕, strong).

The placement of a gastrostomy tube is often used to both provide fixation of the anterior stomach to the abdominal wall and to aid in postoperative venting of the stomach in cases of delayed gastric emptying. One of the first studies promoting an anterior gastropexy to reduce the recurrence rate after laparoscopic hiatal hernia repair described in a prospective series of 28 patients a repair with reduction of the hernia, sac excision, crural repair, antireflux procedure, and routine anterior gastropexy [156]. No type I hernias were included. No recurrences were reported in up to 2 years’ follow-up evaluation. This finding has been supported by others; a study of 89 patients with large hiatal hernias undergoing laparoscopic repair concluded that the addition of an anterior gastropexy significantly reduced recurrent hernias [103]. Other reports concluded the opposite.

Medium-term outcomes in 116 patients having laparoscopic PEH repair [157], with and without gastropexy, found no significant difference in recurrence rate.

The obese population has been separately studied; a report of a series of hiatal hernia repairs compared a group having the addition of a sleeve gastrectomy to the repair to another group having the addition of a gastrostomy tube gastropexy to the repair; medium-term outcomes were inferior with hernia repair and gastropexy [71].

Liberal gastrostomy tube placement for decompression and enteral access is promoted in a recent retrospective study after repair of an intrathoracic stomach. Sixty percent of the patients in this series had a gastrostomy tube placed intraoperatively, which was required postoperatively for decompression and/or providing medications [69].

Some authors have described hernia reduction and gastropexy alone without cruroplasty or sac excision [158, 159], particularly in high-risk symptomatic patients. Mortality and morbidity were low, but radiological recurrence was 22 % at 3 months. Results are inferior to formal repair techniques, so gastropexy alone should not be the aim of surgery but rather a fallback option.

Postoperative management

Medical management

Guideline 20

Because early postoperative dysphagia is common, attention should be paid to adequate caloric and nutritional intake (⊕, strong).

Sudden increases in intra-abdominal pressure are thought to predispose the patient to early anatomical failure of the fundoplication and the hiatal hernia repair [73]. It is suggested that early postoperative gagging, belching, and vomiting are predisposing factors for anatomical failure and the need for revision [73] and therefore should mandate early and aggressive therapy if they occur. Gastric distension should be recognized early because it can be potentially dangerous in the immediate postoperative phase [160] and can be treated successfully by the placement of a nasogastric tube [69] or, in cases where an intraoperative gastrostomy tube was placed, by venting the stomach through this tube.

Because early postoperative dysphagia rates can be up to 50 %, the general recommendation is for slow advancement of diet from liquids to solids. Attention should be paid to adequate caloric and nutritional intake in the postoperative period. Expert opinion suggests that most patients will lose 10–15 pounds (4.5–7 kg) with laparoscopic fundoplication and hernia repair followed by a graduated diet from liquids to soft solids. If dysphagia persists or weight loss occurs of more than 20 pounds (>9 kg), evaluation and intervention for the dysphagia should be considered.

Postoperative contrast studies

Guideline 21

Routine postoperative contrast studies are not necessary in asymptomatic patients (⊕⊕⊕, strong).

There are no studies supporting routine contrast imaging after hiatal hernia repair. If patients show symptoms of severe dysphagia or the possibility of a leak of perforation, a contrast study is indicated. Routine radiographic follow-up shows a greater incidence of recurrence than symptomatic follow-up alone [4], but because most recurrences are small and asymptomatic [161], many suggest that routine radiographic follow-up is not indicated.

Revisional surgery

Guideline 22

Revisional surgery can safely be undertaken laparoscopically by experienced surgeons (⊕⊕⊕, strong).

Recurrent hiatal hernia repair is indicated when the symptoms match anatomical findings [43]. The revisional surgery can often be completed laparoscopically in experienced hands [43, 89]. Any previous fundoplication should be taken down in its entirety, the right and left crura exposed, and the hernia sac excised. Attention should be directed to ensuring adequate intra-abdominal esophageal length [89]. The success of laparoscopic revisional hiatal hernia surgery approaches that of the primary repair [162], although there remains an increase in recurrence rates. Mesh can be safely used in revisional surgery [163], although there are inadequate and underpowered data to support its use.

Pediatric considerations

Pediatric guidelines—indications for surgery

• Guideline 23—Symptomatic hiatal hernias in children should be surgically repaired (⊕⊕, weak).

• Guideline 24—A laparoscopic approach in children is feasible. Age or size of the hernia should not be an up-front contraindication to laparoscopy (⊕⊕, weak).

Indications for surgery—pediatric

Hiatal hernias in children may be congenital or acquired. The incidence in this age group is low, and subsequently there is a lack of high-quality data for management in the pediatric population. Genetic factors such as familial inheritance [164], right isomerism [165], Marfan syndrome [166], and collagen type III alpha I [167] may play a role, although most cases are sporadic. Children with a hiatal hernia and symptomatic gastroesophageal reflux have been shown to exhibit high failure rates of conservative management in a prospective trial of 718 patients [168]. Therefore, surgical repair with concomitant fundoplication is advised in this cohort.

Clinically, children with hiatal hernias may be asymptomatic or may present with reflux symptoms including vomiting, aspiration, respiratory distress, recurrent pneumonia, feeding problems, failure to thrive, melena, anemia, and gastric volvulus in rare cases [168–170]. Occasionally they are diagnosed on chest radiographs performed for other reasons [169]. An upper gastrointestinal (GI) contrast study is the most efficient and reliable diagnostic test to delineate the gastroesophageal anatomy [166] and to exclude other causes of vomiting such as malrotation. Esophagoscopy is helpful to evaluate for esophagitis, and pH probe studies allow quantitative assessment for gastroesophageal reflux, which is present in over half of children with hiatal hernias [171]. In some cases, hiatal hernias diagnosed in infancy may spontaneously mature and resolve. A 20- to 40-year follow-up study of 118 patients with hiatal hernia in infancy showed that the hernia persisted into adulthood in 53 % of patients treated nonsurgically, and that 17 of 24 patients who had undergone surgery as a child had a hiatal hernia on upper GI contrast study as adults [172]. Heartburn was common in both the conservatively and surgically managed groups, and one patient in each group developed Barrett esophagus.

Although transthoracic and transabdominal repair has been described, the latter is preferred by most pediatric surgeons [171].

Pediatric guidelines—technical considerations

• Guideline 25—Gastroesophageal reflux in pediatric patients with a hiatal hernia should be addressed by a concomitant antireflux procedure (⊕⊕, weak).

• Guideline 26—The current standard of care in children is either excision of the hernia sac or disconnection of the sac from the crura (⊕⊕⊕, weak).

• Guideline 27—To lower the risk of postoperative PEH after fundoplication in the pediatric population, minimal hiatal dissection should be performed (⊕⊕, weak).

• Guideline 28—Plication of the esophagus to the crura may decrease recurrence in children (⊕, weak).

Technical considerations—pediatric

The majority of reports include an antireflux procedure in patients with preoperative gastroesophageal reflux [171]. In fact, 12 of 20 children developed recurrent reflux symptoms after a simple hiatal repair without an antireflux procedure in an historic cohort of one study [170]. Laparoscopic repair of even large PEH is feasible in the pediatric population [173, 174]. Most reports advocate resection [166, 169, 171, 173, 175] or incision [174] of the hernia sac. Laparoscopic Collis gastroplasty and Nissen fundoplication has been described for severe recurrent reflux in patients as young as 5 years with esophageal atresia, gastroesophageal reflux, and recurrent hiatal hernia [151]. In this series, one out of six patients had a gastric perforation that required open reexploration. Hence, this approach should be individualized to select patients where standard treatment has failed.

The risk of recurrence after paraesophageal hiatal hernia repair and fundoplication is higher in children who exhibit preoperative gagging, retching, and slow gastric emptying [175]. The risk of recurrence was shown to be lower if the esophagus was plicated to the crus in one study of 464 children [175]. Plication in this study, however, was associated with a higher incidence of other perioperative complications. Minimal as opposed to extensive hiatal dissection during the primary antireflux operation also decreased the risk of postoperative PEH from 30 to 7.8 % in a randomized trial of 177 pediatric patients [176].

Summary

Diagnosis

• 1. Hiatal hernia can be diagnosed by various modalities. Only investigations that will alter the clinical management of the patient should be performed (⊕⊕⊕, strong).

Indications for surgery

• 2. Repair of a type I hernia in the absence of reflux disease is not necessary (⊕⊕⊕, strong).

• 3. All symptomatic paraesophageal hiatal hernias should be repaired, particularly those with acute obstructive symptoms or those that have undergone volvulus (⊕⊕⊕⊕, strong).

• 4. Routine elective repair of completely asymptomatic PEH may not always be indicated. Consideration for surgery should include the patient’s age and comorbidities (⊕⊕⊕, weak).

• 5. Acute gastric volvulus requires reduction of the stomach with limited resection if needed (⊕⊕⊕⊕, strong).

Repair of hiatal hernia during bariatric operations

• 6. During operations for Roux-en-Y gastric bypass, sleeve gastrectomy, and the placement of adjustable gastric bands, all detected hiatal hernias should be repaired (⊕⊕⊕, weak).

Predictors of outcome

• 7. Postoperative nausea and vomiting should be treated aggressively to minimize poor outcomes (⊕⊕, strong).

Technical considerations

• 8. Hiatal hernias can effectively be repaired by a transabdominal or transthoracic approach (⊕⊕⊕⊕, strong). The morbidity of a laparoscopic approach is markedly less than that of an open approach (⊕⊕, strong).

• 9. Laparoscopic hiatal hernia repair is as effective as open transabdominal repair, with a reduced rate of perioperative morbidity and with shorter hospital stays. It is the preferred approach for the majority of hiatal hernias (⊕⊕⊕⊕, strong).

• 10. During paraesophageal hiatal hernia repair the hernia sac should be dissected away from mediastinal structures (⊕⊕, strong) and then preferably excised (⊕⊕, weak).

• 11. The use of mesh for reinforcement of large hiatal hernia repairs leads to decreased short term recurrence rates (⊕⊕⊕, strong).

• 12. There are inadequate long-term data on which to base a recommendation either for or against the use of mesh at the hiatus.

• 13. A fundoplication must be performed during repair of a sliding type hiatal hernia to address reflux. A fundoplication is also important during PEH repair (⊕⊕, weak).

• 14. In the absence of achalasia, tailoring of the fundoplication to preoperative manometric data may not be necessary (⊕⊕, weak).

• 15. A necessary step of hiatal hernia repair is to return the gastroesophageal junction to an infradiaphragmatic position (⊕⊕⊕, strong).

• 16. At the completion of the hiatal repair, the intra-abdominal esophagus should measure at least 2–3 cm in length to decrease the chance of recurrence (⊕⊕, weak). This length can be achieved by mediastinal dissection of the esophagus and/or gastroplasty (⊕⊕⊕⊕, strong).

• 17. Gastropexy may safely be used in addition to hiatal repair (⊕⊕⊕⊕, strong).

• 18. Gastrostomy tube insertion may facilitate postoperative care in selected patients (⊕⊕, strong).

• 19. Hernia reduction with gastropexy alone and no hiatal repair may be a safe alternative in high-risk patients but may be associated with high recurrence rates (⊕⊕, weak). Formal repair is preferred (⊕⊕⊕⊕, strong).

Postoperative management

• 20. Because early postoperative dysphagia is common, attention should be paid to adequate caloric and nutritional intake (⊕, strong).

• 21. Routine postoperative contrast studies are not necessary in asymptomatic patients (⊕⊕⊕, strong).

Revisional surgery

• 22. Revisional surgery can safely be undertaken laparoscopically by experienced surgeons (⊕⊕⊕, strong).

Pediatric considerations

Indications for surgery

• 23. Symptomatic hiatal hernias in children should be surgically repaired (⊕⊕, weak).

• 24. A laparoscopic approach in children is feasible. Age or size of the hernia should not be an up-front contraindication to laparoscopy (⊕⊕, weak).

Technical considerations

• 25. Gastroesophageal reflux in pediatric patients with a hiatal hernia should be addressed by a concomitant antireflux procedure (⊕⊕, weak).

• 26. The current standard of care in children is either excision of the hernia sac or disconnection of the sac from the crura (⊕⊕⊕, weak).

• 27. To lower the risk of postoperative PEH after fundoplication in the pediatric population, minimal hiatal dissection should be performed (⊕⊕, weak).

• 28. Plication of the esophagus to the crura may decrease recurrence in children (⊕, weak).

Appendices

Appendix 1

See Tables 3 and 4.

Table 3 Medline search strategy, February 2011

Table 4 GRADE system for rating the quality of evidence for SAGES Guidelines

Appendix 2

This document was prepared and revised by the SAGES Guidelines Committee: Geoffrey P. Kohn, MBBS (Hons) MSurg; Raymond R. Price, MD (Co-Chariman); Steven R. Demeester, MD; Joerg Zehetner, MD; Oliver J. Muensterer, MD, PhD; Ziad T. Awad, MD; Sumeet K. Mittal, MD; William S. Richardson, MD (Chairman); Dimitrios Stefanidis, MD, PhD (Co-Chairman); Robert D. Fanelli, MD (Past Chairman); Robert A. Andrews, MD; Goffredo O. Arena, MD; Edward D. Auyang, MD; Simon Bergman, MD; Patrice R. Carter, MD; Ronald Hanson Clements, MD; Giovanni Dapri, MD; Elias Darido, MD; Teresa Catherine deBeche-Adams, MD; David Bryan Earle, MD; David S. Edelman, MD; Erika K. Fellinger, MD; Shannon A. Fraser, MD; Jeffrey A. Genaw, MD; Melanie Goldfarb, MD; Stephen P. Haggerty, MD; Celeste M. Hollands, MD; William Borden Hooks III, MD; William W. Hope, MD; Ifeoma Jacqueline Igboeli, MD; Lisa R. Martin Hawver, MD; Daniel T. McKenna, MD; Erica A. Moran, MD; David W. Overby, MD; Thomas P. Rauth, MD; Arthur Lee Rawlings, MD; Kurt E. Roberts, MD; Alexander Steven Rosemurgy, MD; John Scott Roth, MD; Alan A. Saber, MD; Shean Satgunam, MD; Tejinder Paul Singh, MD; Bala Gangadhara Reddy Thatigotla, MRCSEd; and Marc Zerey, MD. This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).