Laparoscopic surgical repair is considered the treatment of choice for symptomatic LHH [6]. However, the long-term durability of laparoscopic LHH repair is still a matter of debate since there is a paucity of published data regarding long-term clinical and anatomical outcomes. Furthermore, despite wide observation periods reported by the available literature, the mean follow-up time of single patients rarely exceeds 5 years [9,10,11].

For instance, Blake et al. reported the patient-reported outcomes of 235 patients who underwent LHH repair between 2004 and 2016. The results of the clinical questionnaire administered up to 11 years postoperatively showed significant and lasting symptom improvement, with more than 85% of patients reporting excellent satisfaction at all time points. However, objective follow-up was available only one year after surgery, showing that 8.7% and 2.4% of patients had < 2 cm and > 2 cm hiatal hernia recurrence rates, respectively [16].

Also, La Page et al. reviewed a prospectively maintained database of 455 patients submitted to LHH repair without mesh from 1991 to 2012, with open and laparoscopic approaches, at a single tertiary referral center in Australia. The median follow-up was 32 months (range 0–235 months), the overall reported recurrence rate was 35.6% at a mean of 42 months after surgery, and revision operations were performed in 4.8% of the study population. However, the favorable results of surgery on symptom control were not affected by the presence of a recurrence [17].

These results are consistent with those reported by other authors, showing no direct correlation between the presence of radiological recurrences and worse clinical outcomes of LHH repair [18, 19]. In fact, recurrences after LHH repair are relatively common [2]. According to a meta-analysis performed by Rathore et al., including 13 retrospective studies on the surgical outcomes of laparoscopic LHH repair, the “true” incidence of hiatal hernia recurrence detected with barium esophagogram was 25.5%. However, when considering symptomatic recurrence, the rate decreases to 14%. Furthermore, only 5% of patients required reoperative surgery after LHH repair [7]. Therefore, more clinically significant outcomes, such as the need for revisional surgery, have been proposed as the most valuable endpoints for the objective assessment of laparoscopic LHH repair [8].

In this study, we reported a long-term symptomatic hernia recurrence rate of 16.2% and a reoperation rate of 10.2%, which compares favorably with previously published series [20, 21]. The median time-to-redo was 12 months, meaning that most of symptomatic recurrences requiring revisional surgery occurred within the first year after surgery.

Recurrent hiatal hernias remain a major concern after laparoscopic LHH repair. We strongly adhere to some essential technical surgical principles in an attempt to reduce the rate of postoperative recurrences, such as extensive mediastinal dissection, hernia sac excision, tension-free hiatoplasty, and the addition of a fundoplication [14]. Depending on intraoperative findings, we adopted a selective approach to mesh cruroplasty and esophageal lengthening procedures for short esophagus.

The addition of prosthetic materials for crural repair is still a matter of debate. On the one hand, short-term results of randomized clinical trials have demonstrated that mesh-augmented cruroplasty was associated with a reduced recurrence rate compared to cruroplasty alone [22,23,24]. However, discordant results were reported in later studies, and controversies remained regarding the optimal shape, size, material, and fixation technique of prosthetic reinforcement [25, 26]. Furthermore, mesh-related complications, whose true incidence might be underreported in the literature, could lead to serious consequences that might outweigh the reduced risk of recurrences [27].

More recently, Petric et al. performed a systematic review and meta-analysis, including seven randomized clinical trials, that compare sutured vs. mesh-augmented cruroplasty, showing no significant differences between the two techniques in terms of patient satisfaction and rate of recurrences, both in the short-term (10.1% mesh vs. 15.5% sutured, p = 0.22) and in the long-term (30.7% mesh vs. 31.3% sutured, p = 0.69) follow-up [28]. Similar results have been reported by Angeramo et al. in another recent systematic review and meta-analysis, which also highlighted the higher overall morbidity associated with non-absorbable mesh (RR 1.45, 95% CI 1.24–1.71, P < 0.01) [29].

In our series, 26 patients (15.8%) underwent mesh hiatal repair, both with absorbable and non-absorbable materials, and we did not experience any mesh-related complications. In this study, we adopted a selected approach to mesh cruroplasty, depending on the size of the hiatal defect evaluated intraoperatively. In the case of a wide hiatal opening, where a primary suture would lead to the tearing of diaphragmatic muscle fibers due to excessive tension, mesh-augmented cruroplasty was performed as a bridge to cover the gap of an incomplete crural closure. This choice could explain the worse results associated with mesh cruroplasty compared to hiatoplasty alone, which we have found in our study; in fact, meshes were added in more complex cases, at higher risk of recurrence due weakened diaphragmatic pillars.

Controversy still exists regarding the optimal surgical approach for the management of LHH. The need to add a fundoplication during LHH repair is still a matter of debate; according to a recent meta-analysis including 22 studies for a total of 8600 patients, there was a trend toward a higher rate of GERD, hernia recurrence, and reoperation when fundoplication was not performed, but a lower risk of dysphagia; however, these data did not reach statistical significance [30]. There is no consensus on the optimal type of wrap; the most commonly performed are Nissen, Toupet of Dor [31]. In our study, five patients had ineffective esophageal motility on preoperative manometry and underwent Toupet fundoplication in order to reduce the mechanical obstacle to the passage of the food bolus offered by the partial posterior wrap. At univariate analysis, Toupet fundoplication appeared to be associated with worse outcomes than Nissen fundoplication; however, these results were not confirmed at multivariable analysis.

The strengths of our study are the large number of LHH patients and the long follow-up period for each patient. However, our study has limitations; first, its retrospective nature. Second, some patients could have experienced a symptomatic recurrence and been reoperated elsewhere. However, this is an unlikely scenario since our Institution is a referral center for complex surgery such as primary and revisional LHH repair. Finally, only symptomatic patients underwent instrumental examination; therefore, the exact rate of recurrences could have been underestimated in this study. However, the overall recurrence rate (symptomatic and asymptomatic recurrences) was not the primary outcome of our study, the presence of small asymptomatic recurrent hiatal hernias has no clinical significance, and the lack of need for instrumental examination confirms the good clinical results of LHH repair at very long follow-up.