Laparoscopic Fundoplication with Mesh Repair of a Large Type Iii Hiatal Hernia

Mixed (type III) hiatal hernias – with sliding and paraesophageal components – are uncommon, accounting for 10-15% of all hiatal hernias. Symptoms are that of gastroesophageal reflux disease. The paraesophageal hernia may get incarcerated and present as an emergency. We present a 50-year old patient with symptoms of severe reflux disease who was diagnosed with type III hiatus hernia. Laparoscopic mesh repair with fundoplication was performed, as the defect was large. Postoperatively, patient’s symptoms were almost completely relieved. Follow up manometry was done, which showed normal pressure range. Thoracotomies or laparotomies were the traditional methods of surgery for type III hiatal hernias, though now thoracoscopy and laparoscopy are becoming popular. We favor the laparoscopic approach as the hernial sac can be dealt with and crurorraphy with fundoplication can also be done. The hernial sac may or may not be completely excised. Some feel that if it is not excised, the residual sac may be filled with fluid and it can present as paracardiac cyst. Hence it is preferable to excise the hernial sac. Though controversial, we feel mesh repair of hiatus is advisable in case of large hiatal defects. Laparoscopic repair of type III hiatal hernias is more or less well established and carries all the benefits of minimally invasive surgery.