Laparoscopic Hiatal Hernia Repair: Nissen, Toupet and the Mesh Decision

Laparoscopic repair is the preferred approach for symptomatic hiatal hernia in appropriately selected patients. The goal is to reduce the hernia, close the hiatus tension-free, secure adequate intra-abdominal esophagus and restore an anti-reflux mechanism.

Quick answer

Four steps: (1) dissection and reduction, (2) crural closure, (3) adequate intra-abdominal esophagus, (4) Nissen (360°) or Toupet (270°) fundoplication. Mesh is selective, not routine.

Dissection and reduction

The hernia sac is reduced from the mediastinum and the esophagus mobilised to obtain ≥ 2.5–3 cm of tension-free intra-abdominal esophagus; high mediastinal mobilisation or Collis gastroplasty may be added.

Crural closure

The enlarged right and left crura are re-approximated with non-absorbable sutures. Excessive tension may cause dysphagia; a bougie can help calibrate.

Nissen vs Toupet

Nissen is a 360° full wrap with strong reflux control but slightly more dysphagia and gas-bloat. Toupet is a 270° posterior partial wrap preferred with weak peristalsis or dysphagia risk. High-resolution manometry guides the choice.

Gastropexy and complex cases

Large Type III–IV paraesophageal hernias and recurrent repairs may benefit from anterior gastropexy; the wrap is individualised.

Mesh — not routine

Unlike abdominal wall repairs, routine mesh is not recommended at the hiatus. Rare but serious complications (erosion, migration, stricture) are described. Mesh is considered in selected large defects (>5 cm), poor tissue quality or recurrent repairs; biologic or absorbable meshes with keyhole/U-shape techniques are preferred.