Practice-Changing Milestones in Anti-reflux and Hiatal Hernia Surgery: a Single Surgeon Perspective over 27 years and 1200 Operations.

BACKGROUND: There have been steady innovations in hiatal hernia and anti-reflux surgery. The purpose of this article is to provide a historical perspective on practice-changing innovations in the context a single surgeon experience's over a career.

METHODS: Patients undergoing anti-reflux surgery or hiatal hernia repair by a single surgeon from 12/1992 to 3/2020 were reviewed.

DATA COLLECTED: sex, age, hiatal hernia type, operation type, adjuncts used, and additional procedure performed during index operation. Superimposed on this experience are the practice-changing innovations that occurred over this timeframe.

RESULTS: During the time period, 1200 operations were performed. Distributions: Hernia type: I, 707 (58.9%); II-IV, 325 (27.1%); Recurrent/Failed, 168 (14.0%). Type of operation, including laparoscopic and open: Nissen fundoplication: 889 (74.1%); Toupet fundoplication: 162 (13.5%); Collis-Nissen/Toupet fundoplication: 44 (3.7%); hiatal hernia repair without fundoplication (laparoscopic and open): 38 (3.2%); endoluminal fundoplication: 35 (2.9%); hiatal hernia repair with Heller myotomy/ Dor fundoplication: 10 (0.8%); transthoracic Belsey Mark IV: 2 (0.2%); hiatal hernia repair with magnetic sphincter augmentation: 20 (1.7%). Mesh reinforcement: 185 (15.4%). Additional procedures, 210 (17.5%). During this time, these practice-changing innovations occurred: laparoscopic surgery, 48-h pH monitoring, high-resolution manometry, tailoring of fundoplication, energy sources for tissue division and hemostasis, pyloroplasty for symptomatic gastroparesis, the rise and fall of endoluminal therapies, mesh reinforcement, abandonment of short gastric vessel division, and magnetic sphincter augmentation.

CONCLUSIONS: Over the last 27 years, a number of practice-changing advances have been made. These have led to changes in technique and operation selection of anti-reflux and hiatal hernia surgery.