Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis



We aimed to examine the outcomes and utilization of different hiatal hernia repair (HHR) approaches in elective and emergent/urgent settings. Methods: Vizient 2015–2017 database was queried for adult patients who underwent HHR. Patients were grouped into open (OHHR), laparoscopic (LHHR), or robotic-assisted (RHHR), and further stratified by elective or urgent status and severity of illness at admission. Surgical outcomes and costs were compared across all groups. Statistical analysis were done using SPSS v.25.0.


9171 adults were included (OHHR N = 1534;LHHR N = 6796;RHHR N = 841). LHHR was the most utilized approach (74.1%), followed by OHRR (16.7%) and RHHR (9.2%). OHHR was employed three times as frequently in U settings, compared to elective. Overall, OHHR had longer mean length of stay (LOS; 9.41 vs. < 4 days) and higher postoperative complication rates (8.8% vs < 3.8%), mortality (2.7% vs < 0.5%) and mean direct cost ($27,842 vs < $10,407), when compared to both LHHR and RHHR, all p < 0.05. Analysis of mild to severely ill elective cases demonstrated LHHR and RHHR to be better than OHHR regarding complications (p < 0.05), cost (p < 0.001) and LOS (p < 0.013); there were insufficient extremely ill elective patients for meaningful analysis. In the urgent setting, minimally invasive approaches predominate, overtaken by OHHR only for the extremely ill. Despite the urgent setting, for mild-moderately ill patients, OHHR was statistically inferior to both LHHR and RHHR for LOS (p = 0.002, p < 0.0001) and cost (p = 0.0133, p < 0.001). In severe-extremely ill patients, despite being more utilized, OHHR was not superior to LHHR; in fact, complication, cost, and mortality trends (all p > 0.05) favored LHHR.


Our analysis demonstrated LHHR to currently be the most employed approach overall. LHHR and RHHR were associated with lower cost, decreased LOS, complications, and mortality compared to OHHR, in all but the sickest of patients. Patients should be offered minimally invasive HHR, even in urgent/emergent settings, if technically feasible.

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Correspondence to Dmitry Oleynikov.

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Dmitry Oleynikov is stockholder of Virtual Incision Corporation. Salim Hosein, Tyson Carlson, Laura Flores, and Priscila Rodrigues Armijo declare that they have no conflicts of interest.


Dr. Oleynikov is stockholder of Virtual Incision Corporation. Dr. Hosein, Mr. Carlson, Ms. Flores, and Dr. Armijo have nothing to disclose.

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Address for Dr. Dmitry Oleynikov and Dr. Salim Hosein reflect the address at the time the study was performed.

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Hosein, S., Carlson, T., Flores, L. et al. Minimally invasive approach to hiatal hernia repair is superior to open, even in the emergent setting: a large national database analysis. Surg Endosc 35, 423–428 (2021).

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  • Paraesophageal hernia repair
  • Hiatal hernia repair
  • Emergency
  • Minimally invasive surgery