10 Critical Steps of Hiatal Hernia Repair and Anti-Reflux Surgery: An Expert Consensus and Literature Review

Background: There is significant variability in the treatment of hiatal hernias, which has led to various perspectives regarding the proper manner of dissection, repair, and reconstruction. We sought to evaluate and analyze expert opinions, survey data, and the literature to define the critical steps in hiatal hernia repair. Methods: A focus group (focus) of expert foregut surgeons defined and agreed upon a sequence of critical steps of a hiatal hernia repair. Using the data from the focus group, an anonymous survey was compiled and distributed to members of the American Foregut Society (AFS). The survey data (survey) was then compared to the focus for agreement. The compiled focus and survey data was interpreted as expert recommendation (expert). A literature review (literature) was then conducted and compared to expert data for agreement and evaluation of discordance. This was used to define the critical steps of hiatal hernia repair. Results: Of the 10 identified critical steps, there was agreement on 9 of 10 steps between focus and survey. The 1 step with discordance was supported by the literature. Conclusions: Ten critical steps have been identified to help produce a succinct and reproducible approach to hiatal hernia repair. It is believed that adherence to these steps will allow the surgeon to achieve a safe and successful hiatal repair.