Complex and Recurrent Hiatal Hernia Repair Using a Pedicled Rectus Abdominis Flap: Surgical Technique and Case Series

Background: Recurrent hiatal hernias represent a significant surgical challenge, with recurrence rates of 10.2%-25.5% after conventional repairs. Patients with complex recurrent hernias who have undergone multiple operations have limited therapeutic options due to technical complexity and altered anatomy. This study presents a novel autologous salvage technique using a superiorly pedicled rectus abdominis muscle (RAM) flap for complex recurrent hiatal hernia repair. Methods: Between August 2019 and May 2022, four patients with symptomatic recurrent hiatal hernias underwent RAM flap reconstruction after multiple failed conventional repairs. The superiorly pedicled RAM flap, based on the superior epigastric artery, was harvested laparoscopically or via laparotomy and inserted tension-free into the mediastinal cavity through the esophageal hiatus. Outcomes were assessed using clinical evaluation, radiological imaging (computed tomography scan and barium swallow), and Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaires at medium- and long-term follow-up (>2 y). Results: All procedures were technically successful without major complications. The mean hospital stay was 6.5 days. At mean long-term follow-up of 46.5 months, no hiatal hernia recurrences were observed on imaging. All patients demonstrated significant symptom improvement with mean Gastroesophageal Reflux Disease Health-Related Quality of Life score improvement of -23 points at medium-term follow-up, with continued improvement long-term. Minor complications included abdominal bulging in two patients without functional impairment and one incisional hernia requiring revision. Conclusions: The superiorly pedicled RAM flap represents a promising autologous salvage technique for complex recurrent hiatal hernias in patients who have undergone multiple operations, offering durable reconstruction with excellent symptom relief and no recurrences at long-term follow-up. The technique can be performed laparoscopically in selected cases.