Text

Background and objective: The extent of hernia sac resection during hiatal hernia repair, particularly in intrathoracic stomach patients, remains a poorly defined surgical variable, with minimal representation in the literature. No standardized system exists to quantify or compare surgical techniques across patients or institutions.

Objective: To evaluate the clinical impact of hernia sac resection on recurrence, vagus nerve injury, and postoperative function, and to introduce a novel intraoperative classification that stratifies resection into five grades based on anatomical completeness.

Method: We retrospectively analyzed 97 patients who underwent robotic-assisted hiatal hernia repair between January 2020 and December 2024. Hernia sac resection was classified intraoperatively into: Class I (complete resection), Class II (partial resection: IIA—thoracic only, IIB—partial thoracic and diaphragmatic, IIC—diaphragmatic only), and Class III (no resection). Postoperative recurrence and functional outcomes were evaluated and correlated with resection class and patient-specific factors using multivariate analysis.

Result: During a mean follow-up of 30.5 months with complete follow-up of all patients, recurrence occurred in 10 patients (10.3%). Functional outcomes qualitatively improved, revisional procedures were required in 2 patients (2.1%), and vagal nerve injury was observed in 1 patient (1.0%). Complete sac resection (Class I) was achieved in 43.3% of patients, resulting in the lowest recurrence rate (1/42) (1%). Thoracic-only resections (Class IIA) had the highest recurrence (6/21) (6.2%, p=0.002), with Class IIA independently predicting recurrence (OR 16.2; 95% CI 1.81–146.35; p=0.013). Prior hiatal hernia repair was another strong predictor (OR 14.7, p<0.001). Patients with both Class IIA resection and prior surgery demonstrated a synergistically elevated recurrence risk (66.7%).

Summary: Incomplete thoracic-only hernia sac resection (Class IIA) is a strong, independent predictor of postoperative recurrence. Our novel Classification offers a reproducible framework for intraoperative documentation, outcome stratification, and surgical quality assurance. This is the first study to systematically define and analyze the extent of hernia sac resection as an operative variable, filling a notable gap in current surgical literature.