Although many patients can be managed conservatively, symptomatic or complicated hernias often require surgical intervention. Advances in minimally invasive surgery have made laparoscopic repair an increasingly attractive option in carefully selected patients, offering reduced postoperative pain, shorter hospital stays and faster recovery.

In this article, Dr Mohammad Arif presents three recent cases managed successfully using laparoscopic repair reinforced with non-absorbable mesh, highlighting the importance of surgical expertise, multidisciplinary care and appropriate patient selection.

Laparoscopic hernia repair has become an established technique over the past several decades. Repair of diaphragmatic hernias, however, continues to present unique challenges because of the diaphragm’s close relationship with vital thoracic and abdominal structures. Successful management requires meticulous surgical planning, advanced laparoscopic skills and close collaboration with an experienced anaesthetic team, particularly where intra-operative thoracic complications may occur.

Historically, these procedures have been concentrated within major teaching hospitals because of their complexity and the specialist expertise required. Nevertheless, increasing experience in advanced laparoscopic surgery has enabled selected private centres to perform these operations safely in appropriately chosen patients.

The following three cases illustrate different clinical presentations of diaphragmatic and giant hiatal hernias treated laparoscopically in private practice, demonstrating favourable clinical outcomes following minimally invasive repair with non-absorbable mesh reinforcement where indicated.

Why these cases matter

Diaphragmatic hernias may be congenital or acquired following trauma and often remain undiagnosed for many years before symptoms develop. Patients may present with recurrent respiratory infections, chronic gastro-oesophageal reflux, persistent heartburn, chest discomfort or progressive respiratory compromise, depending on the size of the defect and the organs involved.

Delayed diagnosis is not uncommon, particularly after previous thoraco-abdominal trauma, making careful clinical assessment and appropriate imaging essential. These three cases demonstrate the varied ways in which diaphragmatic hernias may present and emphasise the importance of recognising when surgical intervention is appropriate. While each patient presents unique anatomical considerations, the common objective remains restoration of normal anatomy while minimising postoperative morbidity. This case series illustrates how laparoscopic repair can achieve these goals in experienced hands.

Case 1: Delayed presentation following penetrating trauma

A 42-year-old police officer presented with recurrent episodes of pneumonia following a stab injury to the left posterior chest sustained 22 years earlier. At the time of injury, he underwent insertion of a chest drain for management of a haemopneumothorax before being discharged.

Subsequent CT imaging confirmed a left diaphragmatic hernia containing part of the gastric fundus, transverse colon, omentum and pancreatic tail. A lateral chest radiograph demonstrated collapse of the left lower lung zone.

The patient underwent successful laparoscopic reduction of the hernia contents with primary repair of the diaphragmatic defect using Ethibond sutures reinforced with non-absorbable mesh. A chest drain was removed prior to discharge, and the patient recovered well, leaving hospital on postoperative day five.

Case 2: Giant hiatus hernia causing longstanding reflux

A 64-year-old woman with no significant medical history reported a 15-year history of progressively worsening heartburn.

Assessment revealed that approximately 80% of her stomach, together with part of the transverse colon, had herniated into the thoracic cavity.

Although she had previously been offered open surgical repair, she declined this approach and later presented for reassessment. Following evaluation, she underwent laparoscopic repair consisting of Collis gastroplasty, mesh reinforcement of the giant hiatus hernia and Nissen fundoplication.

Recovery was uncomplicated, and she was discharged home on postoperative day five with an excellent clinical outcome.

Case 3: Progressive symptoms despite medical therapy

A 49-year-old man was diagnosed with a giant hiatus hernia in 2018 after persistent reflux symptoms. Imaging demonstrated that almost the entire stomach, together with the omentum, had herniated through the oesophageal hiatus.

Initial management remained conservative because his symptoms responded to proton pump inhibitors (PPIs). As symptoms progressively worsened and medical therapy became less effective, he elected to proceed with surgery following informed consent.

He underwent laparoscopic hiatal hernia repair with non-absorbable mesh reinforcement and Nissen fundoplication. His postoperative recovery was uncomplicated, and he was discharged on the fifth postoperative day.

Clinical perspective

Although each patient presented with different symptoms and anatomical findings, several important themes emerge from this series. Careful patient selection, comprehensive pre-operative assessment and multidisciplinary peri-operative planning remain fundamental to successful outcomes.

These cases also illustrate the potential advantages of minimally invasive surgery when performed by experienced laparoscopic teams. Reduced postoperative discomfort, shorter hospital stays and favourable recovery were consistently observed, while mesh reinforcement provided durable repair where appropriate.

As laparoscopic expertise continues to expand, carefully selected patients with complex diaphragmatic and giant hiatal hernias may increasingly benefit from minimally invasive management rather than traditional open surgery.

Conclusion

The three cases presented demonstrate that laparoscopic repair represents a safe and effective management option for selected patients with diaphragmatic and giant hiatal hernias. In experienced hands, repair reinforced with non-absorbable mesh can restore normal anatomy while supporting favourable postoperative recovery. Although these procedures remain technically demanding, advances in laparoscopic surgery continue to expand treatment options and improve patient outcomes.

This case series reinforces the important role of minimally invasive surgery in the management of appropriately selected diaphragmatic hernias.