Laparoscopic repair of large hiatal hernias

BACKGROUND: The repair of large hiatal hernias can be technically challenging. Most series describing laparoscopic repair report only symptomatic outcomes and the true recurrence rate, including asymptomatic recurrence, is not well documented. This study evaluated the long-term outcome of laparoscopic repair of large hiatal hernias. METHODS: All patients who had undergone laparoscopic repair of a large hiatus hernia (more than 50 per cent of the stomach in the hernia) with a minimum 2-year clinical follow-up were identified from a prospectively maintained database. A standardized questionnaire was used to assess symptoms and a barium swallow radiograph was performed to determine anatomy. Multivariate analysis was used to identify factors associated with recurrence. RESULTS: Of 100 eligible patients, clinical follow-up was available in 96. Follow-up ranged from 2 to 8 (median 4) years. In patients with preoperative reflux symptoms, there were significant improvements in heartburn and dysphagia scores after surgery. Overall, 80 per cent of patients rated their outcome as good or excellent. Sixty patients underwent a postoperative barium meal examination that identified 14 radiological hernia recurrences (eight small, three medium and three large). Four other patients in this group of 60 had previously undergone reoperation for early and late recurrence (two of each), giving an overall recurrence rate of 18 of 60 (30 per cent). One third of patients with recurrence were totally asymptomatic and the presence of postoperative symptoms did not reliably predict the presence of anatomical recurrence. Younger age and increased weight at operation were independent risk factors contributing to recurrence. CONCLUSIONS: Laparoscopic repair of large hiatal hernias yields good clinical outcome. Recurrence after laparoscopic repair seems to be more common than previously thought. Objective anatomical studies are required to determine the true recurrence rate. The majority of recurrences are not large and do not cause significant symptoms.     

Laparoscopic repair of paraesophageal hiatal hernias

The advent of minimally invasive techniques has brought about a shift in the operative approach of patients with paraesophageal hiatal hernia. Today, the laparoscopic repair of a paraesophageal hiatal hernia has almost completely replaced the open approach through either a laparotomy or a left thoracotomy. The laparoscopic repair of paraesophageal hiatal hernias is a technically challenging operation; however, it is technically feasible and safe, and it is associated with a positive relief of symptoms, decreased postoperative pain, and a rapid return to normal activities (1, 2). This paper describes, step by step, our approach to the laparoscopic repair of a paraesophageal hiatal hernia.     

Laparoscopic repair of parastomal hernias: early results

Background: Open repair of parastomal hernias is associated with high rates of morbidity and recurrence. Laparoscopic repair with mesh has been described, and good results have been reported in small case series with short-term follow-up. The purpose of this study was to review our institutions experience with the laparoscopic repair of parastomal hernias. Methods: Nine patients with symptomatic parastomal hernias (five ileal conduits, two ileostomies, and two sigmoid colostomies) underwent laparoscopic repair with mesh between April 1998 and September 2001. Demographics, operative details, postoperative complications, and hernia recurrences were recorded retroprospectively. Results: All of the patients were men; their average age was 66 years (range, 53–77). A single piece of Gore-Tex Dual Mesh with a slit to accommodate the stoma was used in seven of nine repairs; in the other two patients, two pieces of mesh were used. Concurrent incisional hernias were repaired in three of nine patients (33.3%). The average operating time was 243 min (range, 136–360). The average postoperative length of stay was 4.7 days (range, 2–7). Immediate postoperative complications occurred in three patients (33.3%) (one ileus, one urinary retention, and one ulnar neuropathy). Recurrences developed in four patients (44.4%), and in one patient (11.1%) the stoma prolapsed; all of these failures occurred within 6 months of the operation. One patient died 10 months postoperatively, without evidence of hernia recurrence. Three patients are without evidence of recurrence after 18, 21, and 33 months (average, 24) of follow-up, respectively. Conclusion: In this series, laparoscopic repair of parastomal hernia failed in 56% of patients, all within 6 months of the operation. Although the laparoscopic approach has potential advantages compared to the conventional open methods, the initial results are disappointing. Advances in the technique may improve the early results, and further prospective studies are needed to determine the efficacy of this approach.     

Laparoscopic primary repair of ventral hernias: Early results of a new technique

Epigastric, umbilical, incisional, parastomal, and trocar site hernias are all classified as “ventral” hernias, which constitute a great portion of the surgery in a general surgical practice, and debate still continues regarding the optimal surgical strategy to correct these anatomical defects. Although repairing these hernias using a synthetic material, whether placed open or laparoscopically, has gained wide popularity, there are some situations where the use of a mesh is either unnecessary or contraindicated. This article presents the cases of 10 patients with some kind of ventral hernia which were all repaired laparoscopically with a primary suturing technique.     

Laparoscopic treatment of large hiatal hernias

Large hiatal or paraesophageal hernias constitute between 5% and 10% of all hiatal hernias. This hernia is a potential threatening complication, and a timely operative correction should be performed in all patients with an acceptable risk. Based on the lessons learned from conventional approach, laparoscopic treatment has confirmed the initial good results with all advantages of laparoscopic surgery. Reduction of the hernia, excision of the sac, and approximation of the hiatus followed by selective use of an antireflux procedure and some form of gastropexy constitute the operative steps to obtain optimal postoperative results.     

Laparoscopic Nissen fundoplication with anterior versus posterior hiatal repair: long-term results of a randomized trial

BACKGROUND: Postoperative dysphagia in patients after Nissen fundoplication might be related to the technique used for the closure of the esophageal hiatus. METHODS: A total of 102 patients with gastroesophageal reflux were randomized to undergo laparoscopic Nissen fundoplication with either anterior (47 patients) or posterior (55 patients) repair of the diaphragmatic hiatus. RESULTS: Clinical data at 5 years after surgery were available for 96% of patients enrolled in the trial. There was no significant difference between the 2 techniques for symptoms of dysphagia at the 5-year follow-up evaluation, although more patients who underwent posterior hiatal repair underwent further surgery for dysphagia-related symptoms (8 vs 2). Better control of heartburn was achieved in patients in the anterior hiatal repair group. Patients from both groups were equally satisfied with the overall outcome after surgery. CONCLUSIONS: At the 5-year follow-up evaluation, there was no significant difference in dysphagia between anterior closure and posterior hiatal repair.     

Laparoscopic hiatal hernia repair

Background The recurrence rate after laparoscopic repair of hiatal hernias with paraesophageal involvement (LRHP) is reported to be high. Mesh reinforcement has been proposed with the objective of solving this problem. This study aimed to compare the outcome of LRHP before and after the introduction of mesh reinforcement. Methods Between 1992 and 2003, 56 consecutive patients received LRHP including posterior crurorrhaphy and additional fundoplication. Of these 56 patients, 17 underwent a mesh-reinforced hiatoplasty. Perioperative outcome was assessed retrospectively, and follow-up assessment was performed according to protocol including a barium contrast swallow. Results The follow-up period averaged 52 ± 31 months (range, 9–117 months). The recurrence rate for hiatal hernia without mesh reinforcement was 19% (7/36). No recurrence (0/16) was observed in patients with mesh reinforcement. The intraoperative complication rate was 9%, and the perioperative morbidity rate was 14%. There were neither mesh-related complications nor operation-related deaths. Conclusions Although challenging, LRPH is a successful procedure. The high recurrence rate reported in the literature can be reduced by additional mesh reinforcement.     

Laparoscopic tension-free repair of large paraesophageal hiatal hernias with a composite A-shaped mesh: two-year follow-up

BACKGROUND: Surgical repair of large hiatal hernias is associated with a high recurrence rate when the repair is made by simple cruroplasty. The use of a mesh goes from a reinforcement of a simple cruroplasty to a tension-free repair. We discuss the evolution of this approach and evaluate the outcomes of 27 patients with type II (n = 9), type III (n = 16), and type IV (n = 2) hiatal hernias treated laparoscopically. METHODS: Between November 1999 and October 2003, 27 patients (18 women and 9 men) received laparoscopic repair of large hiatal hernias by means of an A-shaped polypropylene-polytetrafluoroethylene mesh. A total or a partial fundoplication was associated in all cases. The mean age was 60.1 years (range, 36-76 years). The patients presented with symptoms of 2 months to 10 years in duration. Preoperative assessment included an upper gastrointestinal endoscopy, esophageal manometry, 24 hour pH monitoring, and barium swallow. Concomitant esophagitis was found in 16 patients and impaired esophageal peristalsis in 2 patients. Four patients had concomitant gallbladder disease treated at the same time. RESULTS: No conversions occurred in our series. There was no perioperative mortality, and morbidity was low. Follow-up averaged 27 months (range, 6-46 months). There has been 1 recurrence (3.7%), prolonged dysphagia in 4 cases, and no mesh erosion. CONCLUSION: Early results confirm the feasibility of the tension-free repair of large hiatal hernias and the effectiveness of the composite A-shaped mesh. Long-term follow-up for all patients is necessary to determine the real incidence of recurrence.     

Laparoscopic surgeries in the treatment of hiatal hernias

Immediate and long-term results of treatment of 132 patients with hiatal hernias are analyzed. Indications for surgery are determined. Complications during and after laparoscopic antireflux surgeries are analyzed.     

腹腔镜食管裂孔疝修补术

<正>食管裂孔疝(hiatus hernia)是指食管腹段、食管胃连接部和部分胃组织通过膈食管裂孔凸入胸腔形成的一种疝。食管裂孔疝属膈疝中最常见的一种,占90%以上,多见于40岁以上的患者,其症状主要表现为胸     

Laparoscopic repair of strangulated hernias

Background Although laparoscopic transabdominal preperitoneal polypropylene (TAPP) hernia repair is now a recognized procedure for groin hernia repair in patients undergoing elective surgery, there is a scarcity of data on TAPP repair in emergency situations such as those involving strangulated hernias. Methods Unless contraindicated, the authors’ department considers laparoscopic TAPP repair the procedure of choice for all strangulated hernias. A prospective database of 1,532 consecutive hernia repairs performed between May 1998 and April 2004 was reviewed. Results A total of 28 irreducible strangulated hernias were observed and repaired through laparoscopic TAPP. There were three conversions (10.7%): one because of extensive adhesions and two because of bowel distention. Resection became necessary in 9 (36%) of the 25 cases involving effective TAPP repair of strangulated hernias. The mean operation time, with and without resection, was 103 and 55 min, respectively. The rate of postoperative morbidity was 4% because of one inguinal hematoma case. During a mean follow-up period of 340 days, there were no recurrences after TAPP repair. Conclusions For selected patients, the TAPP approach appears to be a good therapeutic option for strangulated hernias.     

Laparoscopic repair of recurrent hernias

The purpose of this study was to evaluate the results of a laparoscopic approach to recurrent inguinal hernia repair which dissected the entire inguinal floor and repaired all potential areas of recurrence without producing tension. Both a transabdominal preperitoneal and a totally extraperitoneal laparoscopic approach were utilized. Ninety recurrent hernias were repaired in 81 patients. The patients had 26 indirect, 36 direct, and 26 pantaloon recurrent hernias of which eight had a femoral component. In all but one patient the primary operations were open anterior repairs. The median follow-up was 14 months, ranging from 1 to 28 months. Patients returned to normal activities in an average of 1 week. The only recurrence observed was in the one patient whose primary repair was laparoscopic. When the entire inguinal floor of the recurrent hernia was redissected and buttressed with mesh, early recurrence was eliminated and recovery was shortened.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Laparoscopic treatment of paraesophageal and large mixed hiatal hernias

Background: Laparoscopic treatment of large mixed hiatal hernias was attempted in eight patients. Methods: One patient (12.5%) was converted to open surgery due to difficulty in repositioning the LES into the abdomen resulting from a shortened esophagus. One left pleural tear occurred intraoperatively and was repaired without further consequence. Median duration of the operation was 150 min (range 120–300 min). Results: No postoperative complications were recorded. All patients are asymptomatic after a median follow-up of 14 months (range 7–15 months). Correct repositioning of the stomach was confirmed by radiological evaluation 1 month after surgery. Early functional results are good. (One asymptomatic gastroesophageal reflux was detected and medical treatment was undertaken). Conclusions: Laparoscopic crural repair and fundoplication are feasible even in paraesophageal and large mixed hiatal hernias. Advantages of the minimally invasive approach are clear in terms of morbidity, patient comfort, and duration of hospital stay. Nevertheless, long-term assessment is required to confirm the effectiveness of the laparoscopic approach in patients with large mixed hiatal hernias.