A simplified laparoscopic technique for mesh placement in ventral hernia repair

The use of a large synthetic mesh for laparoscopic repair of significant ventral abdominal wall defects may be accompanied by technical difficulties resulting from improper orientation and positioning of the mesh over the defect. We suggest a technique based on initial fixation of the mesh center to the central point of the defect, and subsequent centrifugal attachment of the mesh to the abdominal wall. This technique is advantageous because it leads to precise orientation and positioning of the synthetic patch and to significant reduction of the time needed for its reinforcement over and around the defect. Received: 25 September 1998/Accepted: 27 November 1998     

Nerve irritation after laparoscopic hernia repair

Background: Between October 1992 and May 1996, 893 hernia repairs were performed at the Surgical Clinic in Mannheim: 448 (50%) using laparoscopy (TAPP-method) and 445 (50%) using the conventional anterior approach (Shouldice). Materials and methods: For this study, 723 (81%) of these repairs were followed up in a prospective trial of postoperative nerve irritations. Results: The rate of nerve entrapment in the laparoscopic group was 4.2% (n= 19), and in the group that underwent conventional surgery 1.8% (n= 8). The genitofemoral nerve was affected with particularly high frequency (2%), and the ilioinguinal nerve and lateral cutaneous nerve of the thigh (LCNT) each was affected in 1.1% of the cases. Conclusions: Reduction in the number of clips used and careful attention to the anatomic nerve course during preparation and placement of mesh led to a significant reduction in the occurrence of nerve irritations. In the last 100 patients who underwent laparoscopic hernia repair, only one nerve lesion was seen. Received: 27 January 1998/Accepted: 14 January 1999     

A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair

Background: The aim of this prospective, randomized, controlled clinical study was to compare laparoscopic transabdominal preperitoneal (TAPP) hernia repair with a standard tension-free open mesh repair (open). Methods: A total of 108 low-risk patients with unilateral (primary or recurrent) or bilateral hernias were randomized to TAPP (group 1 = 52 cases) or open (group 2 = 56 cases). The outcome measures included operating time, complications, postoperative pain, return to normal activity, operating theater costs, and recurrences. Results: The mean operative time was longer for the TAPP than for the open group only in unilateral primary hernias. At rest, the median Visual Analog Scale (VAS) score was higher for group 1 than group 2 at 48 h postoperatively. Mild to discomforting pain in the inguinal region after 7 days, night pain after 30 days, and inguinal hardening after 3 months were more frequent in group 2 than group 1. No significant differences were observed in return to normal activities between the groups. One hernia recurrence was observed after 1 month in group 1. TAPP was significantly more expensive than open. Conclusions: TAPP was associated with less postoperative pain than open. The increase in operating theater costs, however, was dramatic and was not compensated by shorter time away from work. TAPP should not be adopted routinely unless its costs can be drastically reduced. Received: 10 June 1997/Accepted: 6 October 1997     

Late rejection of the mesh after laparoscopic hernia repair

We report the first case of late rejection of a mesh after laparoscopic hernia repair. It occurred in a 48-year-old man who had had a laparoscopic hernia repair by transabdominal preperitoneal approach 3 years earlier. The most characteristic finding was the slow development of a firm mass in the right groin, without pain or fistula. At admission 3 months later, US and CT scans demonstrated a necrotic mass extending into both iliac fossa. The mass was approached through a midline incision. Pus was taken for microscopic examination (negative), and the mesh was removed, along with several staples. Ultramicroscopic examination of the mesh showed breakdown of the fibers, collagen reduction, and no chronic inflammatory cells. No infectious cause of inflammation was identified. Received: 5 May 1997/Accepted: 11 July 1997     

Laparoscopic repair of postoperation ventral hernia

Background: Laparoscopic repair is a new alternative approach to postoperation ventral hernia (POVH). Whether this procedure is accompanied with acceptable operation risk and recurrence rate is not yet established. Methods: During 1996, we performed laparoscopic repair of POVH in 53 patients. Twenty-nine (55%) of these patients had a history of at least one failed hernia repair. The size of the abdominal wall defect varied from 4 × 5 cm to 15 × 20 cm (median, 13 × 9 cm). All operations were performed with the patient under general anesthesia. In all cases, the Gore-Tex® Dual Mesh (W. L. Gore &; Associates, Flagstaff, AZ, USA) was used in sizes varying from 5 × 7 cm to 20 × 30 cm (median, 15 × 12 cm). Results: No deaths occurred as a result of the operations. Intraoperative small bowel injury occurred in two patients (3.6%), which necessitated conversion to laparotomy and performance of small bowel resection in one case and simple suture in the other. Small bowel obstruction developed during the immediate postoperation period in two patients (3.6%). In one of these patients, laparoscopic lysis of adhesions had to be performed. Graft infection with subsequent graft removal occurred in one patient (1.8%), and abdominal wall hematoma developed in another patient (1.8%). Length of hospital stay varied from 2 to 8 days (median, 3.3 days). Follow-up period ranged from 10 to 22 months (median, 17 months). During this period, recurrence of hernia occurred only in one patient in which the mesh had been removed. Conclusions: Laparoscopic repair of POVH is technically feasible. According to our experience, it is the preferred method for patients who have had an earlier failed open repair and patients in whom it is the first repair. Cases with a high likelihood for small bowel injury must be recognized and converted to routine open repair.     

Short-term outcome of laparoscopic paraesophageal hernia repair

Background: The purpose of this study is to determine the morbidity, mortality, and short-term outcomes associated with laparoscopic paraesophageal hernia repair (LPHR). Methods: A series of 58 consecutive LPHRs performed by the author were reviewed with an average 1-year follow-up. Morbidity and mortality rates were compared with historical series of open repairs. Anatomy and technical considerations pertinent to LPHR were reviewed. Results: There were no procedure-related or perioperative deaths in this series of patients undergoing LPHR. Four major complications occurred (7%), two of which required reoperation, all in urgently repaired patients. One patient required conversion to laparotomy (1.7%). Based on symptoms, there were no reherniations. No patients had long-term dysphagia worse than preoperatively. Preoperative symptoms of chest pain, esophageal obstruction, hemorrhage, and reflux were resolved in all patients. Conclusions: LPHR is safe, effective, and compares favorably to historical series of open paraesophageal hernia repair. Received: 24 July 1996/Accepted: 20 November 1996     

Laparoscopic ventral hernia repair

Introduction: Effective surgical therapy for ventral and incisional hernias is problematic. Recurrence rates following primary repair range as high as 25–49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. As an alternative, laparoscopic techniques offer the potential benefits of decreased pain and a shorter hospital stay. This study evaluates the efficacy of the laparoscopic approach for ventral herniorrhaphy. Methods: A retrospective review was performed for 100 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 1995 and May 1998. All patients who presented during this period and were candidates for a mesh hernia repair were treated via an endoscopic approach. Results: One hundred patients underwent a laparoscopic ventral hernia repair. There were 48 men and 52 women. The patients were typically obese, with a mean body mass index (BMI) of 31 kg/m². Each had undergone an average of 2.5 (range; 0–8) previous laparotomies. Forty-nine repairs were performed for recurrent hernias. An average of two patients (range; 1–7) had previously failed open herniorhaphies; in 20 cases, intraabdominal polypropylene mesh was present. There were no conversions to open operation. The mean size of the defects was large at 87 cm² (range; 1–480). In all cases, the mesh (average, 287 cm²) was secured with transabdominal sutures and metal tacks or staples. Operative time and estimated blood loss averaged 88 min (range; 18–270) and 30 cc (range; 10–150). Length of stay averaged 1.6 days (range; 0–4). There were 12 minor and (two) major complications: cellulitis of the trocar site (two), seroma lasting >4 weeks (three), postoperative ileus (two), suture site pain > 2 weeks (two), urinary retention (one), respiratory distress (one), serosal bowel injury (one), and skin breakdown (one) and bowel injury (one). Both of the latter complications required mesh removal. With an average follow-up of 22.5 months (range; 7–37), there have been (three) recurrences. Conclusion: The laparoscopic approach to the repair of both primary and recurrent ventral henias offers a low conversion rate, a short hospital stay, and few complications. At 23 months of follow-up, the recurrence rate has been 3%. Laparoscopic repair should be considered a viable option for any ventral hernia. Received: 11 February 1999/Accepted: 15 March 2000/Online publication: 28 April 2000     

Laparoscopic vs open inguinal hernia repair

Background: The role of laparoscopic inguinal hernia repair is controversial. The aim of this study was to find out whether it is justified to switch from the predominantly modified Bassini repair which the authors had been using to laparoscopic repair. Methods: Randomized controlled trial in 120 eligible patients admitted for elective hernia repair in a university hospital. Results: Sixty patients underwent laparoscopic transabdominal preperitoneal mesh repair; the other 60 patients had an open repair, mostly with the modified Bassini technique. Operative time for laparoscopic repair was significantly longer, mean (s.d.) 95 (28) min vs 67 (27) min (p < 0.001). The mean analogue pain score during the first 24 h after surgery was 36.2 (20.2) in the laparoscopic group and 49.3 (24.9) in the open group (p= 0.006). The requirement for narcotic injections and postoperative disability in walking 10 m and getting out of bed were also significantly less following laparoscopic repair. The postoperative hospital stay was not significantly different, mean 2.6 (1.2) days for laparoscopic repair and 3.0 (1.5) days for open repair (p= 0.1). Patients were able to perform light activities without pain or discomfort sooner after laparoscopic repair, median interquartile range 8 (5–14) days vs 14 (8–19) days (p= 0.013). Patients also resumed heavy activities sooner, but not significantly, after laparoscopic repair, median 28 (17–60) days vs 35 (20–56) days (p= 0.25). The return to work was not significantly different, median 14 (8–25) days after laparoscopic repair and 15 (11–21) days after open repair (p= 0.14). After a mean follow-up of 32 months one patient developed a recurrent hernia 3 months after a laparoscopic repair. Laparoscopic repair was more costly than open repair by approximately $400. Conclusions. Laparoscopic inguinal hernia repair was associated with less early postoperative pain and disability and earlier return to full activities than open repair, but there were no benefits regarding postoperative hospital stay and return to work; laparoscopic repair was also more costly. Received: 23 May 1997/Accepted: 1 August 1997     

Colocutaneous fistula due to polypropylene mesh

Fistulae due to polypropylene mesh are known to occur if the prosthetic mesh is placed close to a hollow viscus. Some cases of enterocutaneous fistula have been reported but there are few cases of fistula affecting the large bowel. It is important to recognize these cases because they are severe complications of the prosthesis and difficult to manage. We present a case of colocutaneous fistula caused by fragmentation of polypropylene mesh and erosion into the sigmoid colon after recurrent incisional hernia repair. Electronic Publication     

Laparoscopic repair of a paraduodenal hernia

Paraduodenal hernias have traditionally been treated by conventional laparotomy. We report the first case of a left paraduodenal hernia treated laparoscopically. A 44-year-old man was admitted with abdominal pain and nausea. Computed tomography and an upper gastrointestinal series with small-bowel followthrough showed accumulation of the small bowel on the left side of the abdomen. A laparoscopic repair was performed. The small bowel was observed beneath a thin hernia capsule. Approximately 1.5 m of jejunum was easily reduced into the abdominal cavity. The hernia orifice (5-cm diameter) was closed intracorporeally with five interrupted sutures. Good exposure of the operative field is critical to this procedure; poor exposure may limit the applicability of the laparoscopic approach. This minimally invasive operation is currently indicated in nonobstructive paraduodenal hernias, especially on the left. Received: 7 October 1996/Accepted: 11 April 1997     

聚丙烯补片应用于腹腔镜完全腹膜外疝修补术治疗体会

目的研究聚丙烯补片应用于腹腔镜完全腹膜外疝修补术（laparoscopic totally extra-peritoneal,TEP）治疗体会。 方法选择2015年1月至2017年2月,河北省张家口市涿鹿县医院TEP患者31例,所有患者均在TEP中应用聚丙烯补片,统计手术前后患者生活质量、各时间点视觉模拟评分法（visual analogue scale,VAS）与并发症率。 结果患者术后生理功能、生命活力、情感职能及社会功能评分较术前均明显提高,差异有统计学意义（P<0.001）。本组患者术后各时间点VAS评分较术前明显降低,差异有统计学意义（P<0.001）。术后患者发生阴囊积液有1例（3.2%）;无腹壁下血管损伤发生;血清肿有1例（3.2%）;总发生率为6.4%。 结论对TEP患者应用聚丙烯补片能显著提高手术效果,促进患者病情早期康复,改善预后提高生活质量。     

Meta-analyses of randomized controlled trials of laparoscopic vs conventional inguinal hernia repairs

Background: Despite randomized controlled trials, the merits of laparoscopic hernia repair remain poorly defined. A meta-analysis may provide a timely overview. Methods: An electronic MEDLINE search, supplemented by a manual search, yielded 14 randomized controlled trials with usable statistical data, involving 2,471 patients. The trials were grouped for separate meta-analyses according to the control operation, either a tension-free or sutured repair, used for comparison. The effect sizes for operating time, postoperative pain, return to normal activity, and early recurrence were calculated, using a random-effects model when the effect sizes were heterogeneous and without subcategories. Results: In all meta-analyses, the laparoscopic operation was significantly longer. When compared with tension-free repairs, the laparoscopic operation showed no advantage in terms of postoperative pain, but resulted in a shorter recovery (marginal significance). As compared with sutured repair, both postoperative pain and recovery were in favor of the laparoscopic operation. When all 14 trials were analyzed together, laparoscopic repairs still had moderately reduced postoperative pain and recovery time. Conclusions: Laparoscopic hernia repair has a modest advantage over conventional repairs. This advantage is more apparent when laparoscopic repairs are compared with sutured repairs rather than tension-free repairs. Received: 9 June 1998/Accepted: 12 January 1999     

Technique and early results of outpatient laparoscopic mesh onlay repair of ventral herniasrid=""id=""Presented to the Canadian Association of General Surgeons at the 67th Annual Meeting of the Royal College of Physicians and Surgeons of Canada, Toronto, Ontario, September 1998

Background: This report describes the technique and early results of a simple outpatient laparoscopic ventral hernia repair. Methods: Data were gathered prospectively for all laparoscopic ventral hernia repairs from January 1996 to December 1997 at a 228-bed hospital. Prolene mesh was stapled to the peritoneal surface of the abdominal wall, leaving sac in situ and mesh uncovered. Patients were seen by the operating surgeon within 2 months, and by an impartial surgeon (J.S.) after 3 to 14 months (average, 7 months; median, 6 months). Results: Repairs involved 44 hernias with orifice sizes 2 to 20 cm in diameter, and an average area of 20 cm². Of these 44 hernias, 36 were postoperative and 8 primary. Furthermore, 20% were recurrent hernias. There were four conversions. The outpatient rate was 98%, with one readmission for ileus. The early recurrence rate was 5%. Conclusions: Laparoscopic mesh onlay repair is a safe, easy, and effective procedure with minimal discomfort and a low early recurrence rate that can be performed safely on an outpatient basis. Received: 15 October 1998/Accepted: 18 October 1999/Online publication: 10 April 2000     

Endoscopically guided percutaneous repair of inguinal hernia through a 2-cm incision

Background: The laparoscopic repair of inguinal hernia is still controversial. Transabdominal preperitoneal repair violates the peritoneal cavity and may result in visceral injuries or intestinal obstruction. The laparoscopic extraperitoneal approach has the disadvantage of being technically demanding and requires extensive extraperitoneal mobilization. The Lichtenstein repair gives good long-term results, is easy to learn, can be performed under local anesthesia, but requires a larger incision. Methods: We describe a novel percutaneous tension-free prosthetic mesh repair performed through a 2-cm groin incision. The inguinal canal is traversed with the aid of a 5-mm video-endoscope and the canal is widened using specially designed balloons. Spermatic cord mobilization, identification and excision of the indirect sac, and posterior wall repair are carried out under endoscopic guidance. Results: Between October 1993 and July 1995, 85 primary inguinal hernia repairs (48 indirect and 33 direct) were performed on 81 patients (80 men, one woman) by the author (A.D.). The mean age was 41 years (range 17–83 years). Six repairs were performed under local anesthetic. Mean operative time was 42 min (range 25–74). Mean hospital stay was 1.2 days (0–3 days). The mean return to normal activity was 8 days (2–10 days). Eight complications have occurred: a serous wound discharge, two scrotal hematomas, a scrotal swelling that resolved spontaneously, wound pain lasting 2 weeks, an episode of urinary retention, and two recurrences early in the series (follow-up 1–22 months). Conclusion: The endoscopically guided percutaneous hernia repair avoids the disadvantages of laparoscopy (i.e., lack of stereoscopic vision, reduced tactile feedback, unfamiliar anatomical approach, risk of visceral injury), yet the use of endoscopic instrumentation allows operation through a 2-cm incision. The minihernia repair thus combines the virtues of an open tension-free repair with minimal access trauma. Received: 21 May 1996/Accepted: 8 August 1996     

A case controlled study of laparoscopic incisional hernia repair

Background: Although the feasibility of laparoscopic incisional herniorrhaphy has been demonstrated, its advantages over the open technique are still unproven. Methods: Fourteen consecutive laparoscopic incisional hernia repairs were compared with 14 matched controls of the open repair done by the same surgeon at the same institution. The controls were selected by a medical record technician not connected with the study. The cases were selected to match diagnoses, ASA status, and body weight as closely as possible. The outcome data for operating time, blood loss, hospitalization, resumption of oral intake, and postoperative complications were analyzed for statistically significant differences. Results: There was no statistical difference between the two groups in the parameters of blood loss, hospital days, or days to oral intake. The laparoscopic operation took 40% longer. Similar complications were seen in both groups. No mortality or early recurrences occurred in either group. Conclusion: Laparoscopic incisional hernia repair of at least moderate complexity had no demonstrable advantage over the open repair in the present study. Received: 28 April 1998/Accepted: 23 March 1999     

Incidence of incipient contralateral hernia during laparoscopic hernia repair

Background: In addition to its well-known benefits of decreased postoperative pain and shorter recovery time, laparoscopic hernia repair has the major advantage of allowing the surgeon to explore the side contralateral to the clinically diagnosed hernia. The purpose of this study was to evaluate the incidence of incipient unsuspected contralateral hernia during totally extraperitoneal (TEP) laparoscopic inguinal herniorrhaphy and to analyze the risks and benefits of identifying these hernias at the time of the initial surgery. Methods: We did a retrospective review of the charts of all of the 724 male patients who underwent laparoscopic TEP repair of 958 groin hernias between September 1991 and September 1999. The initial clinical impression of the existence of unilateral or bilateral hernias was noted and compared to our operative findings. The same surgeon performed all the repairs. Exploration of the contralateral side was performed in a systematic fashion. A second mesh prosthesis was placed if a contralateral hernia was found. Results: Bilateral hernia repair was performed on 234 patients (32.3%). In 62 of them (11.2%), the contralateral hernia was diagnosed only at the time of the procedure. Operative time ranged from 14 to 185 min (median, 38.6). The operative time for the contralateral exploration ranged from 2 to 5 min (median, 2.8). The rate of complications was 4.1%, but no complications were directly related to the exploration of the asymptomatic side. Conclusion: Our study shows that a large number of inguinal hernias are undiagnosed by physical examination (11.2%). Systematic contralateral exploration using the TEP approach is safe and does not greatly increase the operative time. Early identification and repair of a contralateral hernia obviates the need for reoperation, reduces overall costs to the health care system, and eliminates any further work loss for the patient. Received: 24 November 1999/Accepted: 3 February 2000/Online publication: 8 May 2000     

Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair

Background: Unlike sliding hiatal hernias, paraesophageal hiatal hernias (PEH) present a risk of catastrophic complications and should be repaired. To assess laparoscopic repair of PEH, we prospectively evaluated the outcome of 38 consecutive patients with type II (20 patients) or III (18 patients) PEH treated laparoscopically. Methods: With the use of 5 or 6 ports, laparoscopic PEH reduction and repair was attempted. One patient (3%) was converted to an open procedure. In the first 12 patients, the hiatus was closed using varying techniques including the placement of prothestic mesh in 6 patients, and the hernia sac was not routinely excised. In the next 25 patients, the hernia sac always was excised and the hiatus routinely sutured posteriorly to the esophagus. Twenty-nine patients also underwent either a Nissen (n= 27) or Toupet (n= 2) fundoplication, which is now performed routinely. Sutured anterior gastropexy was performed selectively in 10 of the first 20 patients, then routinely, using T-fasteners in the last 17 patients. Barium swallow studies were performed on all patients at 3 to 5 months postoperatively. Results: Mean ± standard error of the mean (SEM) age was 67 ± 2 year (range, 39–92 years; 11 men, 27 women), and the American Society of Anesthesia (ASA) score was 2.5 ± 0.1. The operating time was 195 ± 10 min: 244 ± 15 min in the first 12 patients and 170 ± 11 min in the last 25 patients (p < 0.001). There were three (8%) intraoperation complications, which were treated without sequelae, and four (11%) grade II postoperation morbidities. Median discharge was 3 days, and return to full activity was 14 days. Two patients (5%) died of cardiovascular disease after discharge. Barium swallow revealed 2/35 (6%) PEH recurrences (1 reoperated), 3 (9%) intrathoracic wraps, and 3 (9%) small sliding hiatal hernias. At follow-up of 1 year or more, 6/28 (21%) patients noted mild symptoms of reflux or bloating, but only 1 patient (4%) required medication for these symptoms. Conclusions: Laparoscopic PEH repair offers a reasonable alternative to traditional surgery, especially for high-risk patients. Rapid recovery is achieved with acceptable morbidity and early outcome. Barium x-rays revealed hiatal abnormalities in a significant fraction of patients, many of whom were asymptomatic. Longer follow-up will be required to determine the ideal strategy for management of these patients. Received: 4 April 1998/Accepted: 9 December 1998     

腹腔镜下生物补片修补成人脐疝的临床疗效分析

目的探讨腹腔镜下生物补片修补成人脐疝的有效性和临床疗效。方法回顾性分析2017年1月至2019年1月在首都医科大学附属北京朝阳医院疝和腹壁外科15例行腹腔镜脐疝生物补片修补术患者的临床资料。结果15例患者均顺利完成腹腔镜脐疝修补术,所有患者均行腹腔内生物补片置入修补术。住院时间5~6 d,平均5.5 d。术后随访8~32个月,平均18个月。随访期间无复发,发生包裹性积液1例;术后1个月发生血清肿3例;未见术后发生腹壁慢性疼痛。结论腹腔镜下生物补片修补成人脐疝是一种微创、安全、可靠的方法,并且具有较好的临床效果。     

Pregnancy following laparoscopic mesh repair of ventral abdominal wall hernia

Background:

There are no data on laparoscopic repair of ventral and incisional hernias (LRVIH) in fertile women who intend to have further pregnancies. A unique series is described of 8 women who got pregnant and gave birth after LRVIH.

Methods:

Medical records of 875 consecutive patients who underwent LRVIH were reviewed. Women who gave birth after LRVIH were identified. At follow-up, patients answered a questionnaire on pain, discomfort, recurrence, and problems during pregnancy and delivery and underwent a physical examination.

Results:

Eight patients were identified; all agreed to inclusion. Four women received LRVIH for incisional hernia; 4 were operated on for primary ventral hernia. Median age at LRVIH was 29 years (range, 24 to 34). No postoperative complications occurred. Median time between LRVIH and delivery was 22.5 months (range, 12 to 44). Median follow-up after delivery was 23.5 months (range, 2 to 40). Five patients experienced a tearing pain in the area of hernia repair during the last months of pregnancy. This pain was not continually present and disappeared after delivery in all patients. All infants were born healthy at full term. Seven patients had a vaginal birth and one had a caesarean delivery. There were no major complications during pregnancy or delivery. At control examination, all patients were asymptomatic and, with one exception, without signs of recurrence. One patient had a swelling in the repaired area indicating either recurrence or mesh bulging. Being asymptomatic, she refused any further diagnostics.

Conclusion:

LRVIH in fertile women who intend to have further pregnancies is an acceptable therapeutical option that causes no significant problems during pregnancy or delivery.     

Emergency laparoscopic repair of a paraesophageal hernia

A 63-year-old male with a previously documented paraesophageal hernia presented with acute severe epigastric pain and bloating. He was taken urgently to the operating room for laparoscopic exploration. The hernia sac was reduced with difficulty owing to extensive adhesions and the incarcerated portion of the stomach was mottled and blue. After 10 min of observation the stomach began to resume a normal appearance. The anterior crura were approximated and an anterior gastropexy was performed. The patient was discharged on the 3rd postoperative day and has been asymptomatic since. Paraesophageal hernias with evidence of impending gastric necrosis can be approached laparoscopically as long as basic principles are observed.