LETTER TO THE EDITOR

Hiatal surface area as a basis for a new classification of hiatalhernia

Stavros A. Antoniou • Rudolph Pointner •

Frank-Alexander Granderath

Received: 26 September 2013 / Accepted: 11 October 2013

� Springer Science+Business Media New York 2013

To the Editor,

We were pleased to read an outstanding study, recently

published by Surgical Endoscopy [1]. Grubnik and Maly-

novskyy introduced a novel outcome-oriented and evi-

dence-based classification for hiatal hernias. The authors

divided a cohort of 658 patients into three groups,

according to the hiatal surface area (HSA). The cut-off

values of 10 and 20 cm2 were used to distinguish small

from large and giant hiatal hernias. Their classification was

validated by comparison among groups and analysis of

variance.

The idea of measuring the HSA was introduced in

2007 by Granderath [2] following the clinical observa-

tion of large hiatal defects in a subgroup of patients with

sliding hernias, and small defects in a subgroup of

patients with paraesophageal hernias [3]. Although it was

commonly thought that these cases account for a small

proportion of patients who undergo anti-reflux surgery,

careful observation of the subgroup data of this study

provides important insights with significant clinical

consequences.

The subgroup of patients with small hiatal defects

(HSA \10 cm2) includes 290 patients with type I hernia

(92 %). Similarly, the subgroup of patients with large

hiatal defects (HSA 10–20 cm2) includes 116 patients with

type I hernia (50 %). If the indication for mesh closure

were to be based on the type of hernia (i.e. primary repair

in sliding hernias and mesh application only in para-

esophageal hernias) rather than the HSA, we would sta-

tistically expect an additional number of nine patients of

the type I group with large hiatal defects to experience

hernia recurrence. This would raise the recurrence rate in

this group from 3.0 to 5.2 %. Furthermore, 24 patients with

paraesophageal hernias and small hiatal defects (7.4 % of

patients with HSA \10 cm2) would be subjected to mesh

repair, albeit the expected recurrence rate in this subgroup

is only 3.5 %. Of course, the expected reduction of the risk

for recurrence cannot be calculated, because all cases of

small defects and paraesophageal hernia were subjected to

primary repair.

It would be reasonable for the following comment by

Grubnik and Malynovskyy to be considered the essence of

the rationale to conduct this study: ‘‘…no strong criterion

exists for classifying hiatal hernias, although universal

classification is necessary because the recurrence rate is

strongly dependent on hernia size and Hill’s type.’’ The

authors provide a stable scientific platform for a consensus

on the definition of small, large, and giant hiatal hernia;

such an evidence basis was missing in the literature. The

quality and quantity of the provided data are the apparent

strengths of this report and may not be disregarded,

whereas the authors were meticulous in providing detailed

information on methodology and outcomes.

This study instigates the ongoing discussion on the

definition of large and giant hiatal hernia and challenges

the traditional classification. Since neither the type of the

S. A. Antoniou � F.-A. Granderath

Center for Minimally Invasive Surgery, Neuwerk Hospital,

Monchengladbach, Germany

S. A. Antoniou (&)

Department of General Surgery, University Hospital of

Heraklion, University of Crete, Athinon-Souniou 11, Keratea,

19001 Athens, Greece

e-mail: stavros.antoniou@hotmail.com

R. Pointner

Department of General and Visceral Surgery, Hospital Zell am

See, Zell am See, Austria

123

Surg Endosc

DOI 10.1007/s00464-013-3292-x

and Other Interventional Techniques

hernia nor the size of the hiatal defect are the only deter-

minants of the risk for anatomical recurrence, other known

or anecdotal risk factors, such as the quality of the crural

pillars, obesity, age, and collagen disorders, are expected to

be involved in a grading system, which will evaluate the

probability of recurrence and allow risk-adjusted applica-

tion of mesh hiatoplasty.

Disclosures Drs. S. A. Antoniou, R. Pointner, and F. A. Granderath

have no conflicts of interest or financial ties to disclose.

References

1. Grubnik VV, Malynovskyy AV (2013) Laparoscopic repair of

hiatal hernias: new classification supported by long-term results.

Surg Endosc 27(11):4337–4346

2. Granderath FA (2007) Measurement of the esophageal hiatus by

calculation of the hiatal surface area (HSA). Why, when and how?

Surg Endosc 21:2224–2225

3. Granderath FA, Schweiger UM, Pointner R (2007) Laparoscopic

antireflux surgery: tailoring the hiatal closure to the size of hiatal

surface area. Surg Endosc 21:542–548

Surg Endosc

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