腹腔镜下Toupet胃底折叠术式治疗食管裂孔疝的临床应用

目的 探讨使用腹腔镜行食管裂孔疝修补术的疗效和安全性.方法 对61例食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术,做胃底270°部分折叠术(Toupet术),19例应用补片修补疝缺口,42例采用直接线缝合.结果 61例腹腔镜食管裂孔疝修补术全部获得成功.手术时间30～190 rain,平均手术时间110 min,失血10～50 mL;术后24～48 h进流质饮食,无术后并发症;术后平均住院5.7 d.结论 61例患者的反酸症状均在24 h内缓解,术后停用抗酸药物,修补术具有疗效确定、安全和创伤小的优点,值得进一步推广应用.     

Simultaneous laparoscopic paraesophageal hernia repair and sleeve gastrectomy in the morbidly obese

BackgroundMorbid obesity is associated with increased rates of hiatal and paraesophageal hernias. Although laparoscopic sleeve gastrectomy is gaining popularity as the procedure of choice for morbid obesity, there is little data regarding the management of paraesophageal hernias found intraoperatively. The aim of this study was to evaluate the feasibility and benefits of a combined sleeve gastrectomy and paraesophageal hernia repair in morbidly obese patients.MethodsFrom May 2011 to February 2013, 23 patients underwent laparoscopic sleeve gastrectomy combined with the repair of a paraesophageal hernia. Only 4 patients had a large hiatal hernia documented preoperatively on esophagogastroduodenoscopy (EGD). The body mass index (BMI), operative time, length of stay, and complications were evaluated.ResultsThe average operative time was 165 minutes (115–240 minutes) and length of stay was 2.83 days (2–6 days). All patients were female except for one, with an average age of 53.4 years and a BMI of 41.9 kg/m². There were no complications during the procedures. Mean follow-up was 6.16 months (1–19 months), and mean excess weight loss was 39%. The average cost of admission for a combined procedure ($10,056), was slightly higher than a laparoscopic sleeve gastrectomy ($8905) or laparoscopic paraesophageal hernia repair ($8954) done separately.ConclusionsLaparoscopic sleeve gastrectomy combined with a paraesophageal hernia repair is well-tolerated and feasible in morbidly obese patients. Surgeons should be aware that preoperative EGD is not effective at diagnosing large hiatal or paraesophageal hernias. Surgeons with the skill set to repair paraesophageal hernias should do a combined procedure because it is well-tolerated, feasible, and can reduce the cost of multiple hospital admissions.     

Laparoscopic repair of paraesophageal hernia

Large paraesophageal hernias are generally repaired by reduction of the stomach into the abdomen, sac excision, crural closure, and gastropexy or fundoplication. After gaining experience performing laparoscopic repair of sliding hiatal hernias and Nissen fundoplication we combined laparoscopic access with traditional surgical technique in treating patients with complex paraesophageal hernias.Ten adults, six males and four females, with type III paraesophageal hernias underwent laparoscopic repair between February 1993 and April 1994. The average age of the patients was 60.4 years (range 38–81). Using five ports (three 10 mm and two 5 mm), the stomach was reduced into the abdomen, the hernia sac was resected, and the defect was closed with pledgeted horizontal mattress sutures. In addition, nine patients had a Nissen fundoplication performed and one patient had a diaphragmatic gastropexy.The procedure was completed laparoscopically in all ten cases and the median operating time was 282 min (range 165–430). Two complications occurred, an intraoperative gastric laceration, and a postoperative mediastinal seroma. All patients were discharged on the 2nd or 3rd postoperative day. Eight of nine patients were asymptomatic at last follow-up (mean 8.9 months postop). One patient has mild dysphagia and heartburn from partial migration of the fundoplication into the chest. One patient died 3 months postoperatively of unrelated causes. Paraesophageal hernia can be reduced and repaired safely with laparoscopic access using standard surgical techniques.Presented at the annual meeting of the Society of American Gastro-intestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

Laparoscopic repair of a paraesophageal hiatus hernia without fundoplication

We treated a case of paraesophageal hiatus hernia by laparoscopic repair. The procedure included a reduction of the gastric fundus and duodenal bulbus, closure of the diaphragmatic defect, mesh wrapping of the closure, gastropexy to the diaphragm, and a gastrostomy. Preoperative monitoring of the pH for 24h showed no reflux. Intraoperative intraluminal manometry of the esophagus after hernia reduction showed the pressure of the lower esophageal sphincter to be normal, and thus an antireflux procedure was not deemed to be necessary. The patient was put on a soft diet from postoperative day 2. A postoperative upper gastrointestinal series showed no gastroesophageal reflux. No complications or recurrence of the hiatus hernia have been observed in the 12 months since the operation. Laparoscopic repair of a paraesophageal hiatus hernia with normal pressure of the lower esophageal sphincter, so that fundoplication is not needed, is thus considered to be possible.     

腹腔镜食管裂孔疝修补术143例临床分析

目的 探讨腹腔镜手术治疗食管裂孔疝的可行性和临床应用价值。 方法 对2001年6月至2010年2月天津市南开医院143例食管裂孔疝行腹腔镜食管裂孔疝修补术的资料进行分析。 结果 143例均完成腹腔镜手术,无中转开腹病例,手术时间55～210min,平均86 min;术中出血量40～150mL,平均76mL;术后住院时间3～21d,平均4.6d。术后临床症状均得到缓解,无严重并发症及死亡病例。134例得到随访,随访时间3个月至9年,平均3.8年,手术结果满意率91.67%。8例进固体食物时有轻度哽噎感,5例反酸症状复发,其中4例应用抑酸药物后可控制,1例行开腹手术治疗。结论 腹腔镜治疗食管裂孔疝,充分体现了手术创伤小、恢复快、安全可行、疗效可靠的特点。     

Laparoscopic paraesophageal hernia repair, a challenging operation: Medium-term outcome of 116 patients

Laparoscopic paraesophageal hernia repairs performed in 116 patients between 1992 and 2001 were pro-spectively analyzed. Perioperative outcomes were assessed and follow-up was performed under protocol. There were 85 female and 31 male patients who had a mean (± SD)ageof65 ± 13 years and an American Society of Anesthesiology score of 2.3 ± 0.6. All but two patients underwent an antireflux procedure. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in six patients, and prosthetic closure of the hiatus in six patients. Major complications occurred in five patients (4.3%) with two postoperative deaths (1.7%). Mean follow-up was 30 ± 25 months; 96 patients (83%) have been followed for more than 6 months. Among these patients, 73 (76%) are asymptomatic, 11 (11%) have mild symptoms, and 12 (13%) take antacid medications. Protocol barium esophagograms were obtained in 69% of patients at 6 to 12 months’ follow-up. Recurrence of hiatal hernia was documented in 21 patients (22% overall and in 32% of those undergoing contrast studies). Reoperation has been performed in three patients (3 %). When only the patients with recurrent hiatal hernias are considered, 13 (62 %) are symptomatic but only six (28%) require medication for symptoms. Laparoscopic paraesophageal hernia repair is generally safe, even in this high-risk group. This study confirms a relatively high incidence of recurrent hiatal abnormalities after paraesophageal hernia repair; however, most recurrent hiatal hernias are small and only 3% have required reoperation. Protocol esophagograms detect recurrences that are minimally symptomatic. Improved techniques must be devised to improve the long-term outcomes of laparoscopic paraesophageal hernia repair. Presented at the Forty-Third Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (oral presentation). Supported by the Washington University Institute for Minimally Invasive Surgery.     

腹腔镜治疗食管裂孔疝的临床应用

目的探讨使用腹腔镜行食管裂孔疝修补术的疗效和安全性。方法对26例食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术，其中16例做胃底270。部分折叠术（Toupet术），10例做胃底360°胃底折叠术（Nissen术）。19例应用补片修补疵缺口，7例采用7号丝线缝合。结果26例腹腔镜食管裂孔疝修补术全部获得成功。手术时间30～190min，平均110min，失血10～50ml；术后24～48h进流质饮食，无术后并发症；术后平均住院5．7d。结论26例患者的反酸症状均在24h内缓解，术后停用抗酸药物，修补术具有疗效确定、安全和创伤小的优点。值得进一步推广应用。     

腹腔镜下巨大食管裂孔疝修补术13例分析

目的 探讨腹腔镜下巨大食管裂孔疝应用补片修补和部分胃底折叠术的安全性及有效性。 方法 2006年8月至2009年4月中国人民解放军总医院普通外科对13例巨大食管裂孔疝病人行腹腔镜下裂孔疝补片修补,并同期行部分胃底折叠术。 结果 12例手术成功,1例伴有短食管,手术过程中因分离食管时出现食管损伤中转开胸治疗。手术时间90~180min,平均110min。 术中出血30~120mL,平均50mL,均未输血。12例术后症状完全缓解。术后住院时间3~30d,平均6d。术后随访3~25个月,平均12个月,未发现复发病例。 结论 对于巨大食管裂孔疝,腹腔镜下补片修补是一种安全有效的方法,具有创伤少,恢复快、副反应小的特点。     

Mid term analysis of safety and quality of life after the laparoscopic repair of paraesophageal hiatal hernia

Background Initial experience with the laparoscopic repair of paraesophageal and type III mixed hiatal hernias showed that it is safe and feasible, with excellent immediate and short-term results. However, after a longer follow-up, a recurrence rate of 40% has been demonstrated. Data related to the outcome of paraesophageal hernia repair and the recurrence rate are still lacking. Quality-of-life scores may offer a better means of assessing the impact of surgical treatment on the overall health status of patients. Therefore, we performed prospective evaluation of anatomic and/or symptomatic recurrences after paraesophageal or large hiatal hernia repair. In addition, we investigated the correlation between recurrence and the patients quality of life.Methods All patients after who had undergone repair of paraesophageal of mixed hiatal hernia were identified prospectively from a database consisting of all patients who had had laparoscopic operations for gastroesophageal pathology at our hospital between February 1998 and December 2002. The preoperative symptoms were taken from patients clinical files. In March 2003, all patients with 6 months of follow-up had a barium swallow and were examined for radiological and clinical signs of recurrence. Thereafter, the patients quality of life after surgery was evaluated using three standard questionnaires (Short Form 36 [SF-36], Glasgow Dyspepsia Severity Score [GDSS], and Gastrointestinal Quality of Life Index [GIQLI].Result During the study period, 46 patients had been operated on. The mean age was 63 years (range, 28–93). Thirty seven of them had a follow-up of 6 months. Eight patients (21%) had postoperative gastrointestinal symptoms. Barium swallow was performed in 30 patients (81%) and showed a recurrence in six of them (20%). According to SF-36 and GDSS, the patients postoperative quality of life reached normal values and did not differ significantly from the standard values for the Spanish population of similar age and with similar comorbidities. Successfully operated patients reached a GIQLI value comparable to the standard population. However, symptomatic patients had significantly lower GIQLI scores than the asymptomatic or the Rx-recurrent group.Conclusion The laparoscopic treatment of large paraesophageal and mixed hiatal hernias is not only feasible and safe but also offers a good quality of life on a midterm basis. However, the anatomic and functional recurrence rate is high. The next step is to identify the subset of patients who are at risk of failure and to establish technical alternatives that would ensure the durability of the repair.Presented in foster format at the 2003 scientific meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, March 2003, and as a free paper at the 10th congress of the European Association for Endoscopic Surgery (EASES), Glasgow, Scotland, United Kingdom, June 2003     

Laparoscopic management of large paraesophageal hiatal hernia

Background: Large paraesophageal hernias (POHs) predominantly occur in the elderly population. Early repair is recommended to avoid the risks associated with gastric volvulus. Methods: Data were collected prospectively during an 8-year period. Laparoscopic repair of POHs initially included circumcision of the sac and mesh hiatal repair. Sac excision and suture hiatal repair were later adopted. A fundoplication was also included, initially as a selective procedure. Results: Fifty-three patients with large POHs were treated by one surgeon. All had attempted laparoscopic repair, with four conversions to an open procedure. Symptomatic hernia recurrence occurred in five patients (9%). The 21 patients who had sac excision, hiatal repair, and fundoplication have remained free of symptomatic recurrence. The postoperative morbidity rate was 13%, with one death. Conclusions: Laparoscopic repair of large POHs remains feasible. We advocate complete sac excision, hiatal repair, fundoplication, and gastropexy to prevent early recurrence.     

腹腔镜食管裂孔疝修补术并发症的预防

目的探讨使用腹腔镜行食管裂孔疝修补术的疗效和安全性。减少手术并发症,随访腹腔镜治疗食道裂孔疝的效果。方法对280例食管裂孔疝患者使用腹腔镜行食管裂孔疝修补术,其中132例做胃底270°部分折叠术（Toupet术）,148例做胃底360°折叠术（Nissen术）。36例应用补片修补疝缺口,剩余患者采用直接缝合。结果 280例腹腔镜食管裂孔疝修补术全部获得成功。手术时间30～190min,平均手术时间110min,失血10～50ml;术后24～48h进流质饮食,无术后并发症;术后平均住院5.7d。结论腹腔镜食道裂孔疝修补术具有疗效确定、安全和创伤小的优点。并发症率极低。     

Congenital paraesophageal hiatal hernia: pitfalls in the diagnosis and treatment

Purpose

The aim of this study was to analyze pitfalls in the diagnosis and treatment of congenital paraesophageal hiatal hernia (PEHH).

Methods

Between 1992 and 2004, the records of 5 infants with PEHH were retrospectively reviewed for age, sex, presenting symptoms, radiological studies, operative findings and approaches, and outcomes.

Results

All cases (3 male, 2 female) had right-sided hernias. They had clinical features of recurrent chest infections and intermittent vomiting that were present since birth in 3. Three presented acutely ill with findings of respiratory distress and vomiting. Three were referred with misdiagnoses of reflux disease, thoracic mass, and bronchopneumonia. On the chest x-rays of 3 cases, there were paracardiac opacities suggesting a mass lesion. According to the upper gastrointestinal series and/or computed tomography findings, 4 cases had a combination of sliding and paraesophageal hernia, and the remainder one had pure rolling hiatus hernia. Three had obstruction owing to organoaxial volvulus and required an emergency operation. All cases had a large hernia orifice. Four had gastroesophageal junction (GEJ) displaced into the thorax, and in 3, the stomach was found to be twisted, and transverse colon with omentum was also in the thorax in 2. In the remainder, the GEJ was in its normal position with herniated stomach. None of the cases had normal gastrosplenic and gastrocolic ligaments. Surgical repair included resection of the sac, closure of the hiatal defect, and Thal procedure. Two had intestinal malrotation, with right ovarian torsion and ventricular septal defect, respectively. Postoperative ventilation was required in one who later died. At a mean follow-up of 2 years, the other 4 had no symptoms related to the disease, and no evidence of recurrence or reflux was noted on control upper gastrointestinal series.

Conclusion

Congenital PEHH may be difficult to diagnose. It is frequently complicated and associated with morbidity and even mortality. If the defect is large and associated with displacement of GEJ into the thorax, adding an antireflux procedure to the repair is appropriate.     

Laparoscopic mesh hiatoplasty for paraesophageal hernias and fundoplications

Background Little grade A medical evidence exists to support the use of prosthetic material for hiatal closure. Therefore, the authors compiled and analyzed all the available literature to determine whether the use of prosthetic mesh in hiatoplasty for routine laparoscopic fundoplications (LF) or for the repair of large (>5 cm) paraesophageal hernias (PEH) would decrease recurrence. Methods A literature search was performed using an inclusive list of relevant search terms via Medline/PubMed to identify papers (n = 19) describing the use of prosthetic material to repair the crura of patients undergoing laparoscopic PEH reduction, LF, or both. Results Case series (n = 5), retrospective reviews (n = 6), and prospective randomized (n = 4) and nonrandomized (n = 4) trials were identified. Laparoscopic procedures (n = 1,368) were performed for PEH, gastroesophageal reflux disease (GERD), hiatal hernia, or a combination of the three. Group A (n = 729) had primary suture repair of the crura, and group B (n = 639) had repair with either interposition of mesh to close the hiatus or onlay of prosthetic material after hiatal or crural closure. The use of mesh was associated with fewer recurrences than primary suture repair in both the LF and PEH groups. The mean follow-up period did not differ between the groups (20.7 months for group A vs. 19.2 months for group B). None of the papers cited any instance of prosthetic erosion into the gastrointestinal tract. Conclusions The current data tend to support the use of prosthetic materials for hiatal repair in both routine LF and the repair of large PEHs. Longer and more stringent follow-up evaluation is necessary to delineate better the safety profile of mesh hiatoplasty. Future randomized trials are needed to confirm that mesh repair is superior to simple crural closure.     

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.     

Laparoscopic diagnosis and repair of Spigelian hernia: A case report and literature review

IntroductionSpigelian hernias are a rare type of hernia which protrude through the abdominal wall at the semilunar line. They are especially difficult to diagnose due to their location and non-specific symptoms and are often overlooked because of their positioning between muscular layers. Patients may present with localized pain which can aid the diagnosis. CT and ultrasound are also helpful.Presentation of case: We present the case of a 75-year-old female patient who presented to Hialeah Hospital with a one-year history of abdominal pain localized to the left lower quadrant.DiscussionA Spigelian hernia containing omentum, was found during a diagnostic laparoscopy. The hernia was reduced, and the abdominal defect was repaired via primary repair, reinforced by mesh. The patient recovered uneventfully.ConclusionNonspecific physical exam findings and inconclusive imaging studies represented a diagnostic challenge. Here we discuss a case of a Spigelian hernia discovered through diagnostic laparoscopy.