Laparoscopic repair of large hiatal hernia with teres ligament: midterm follow-up

Background Although laparoscopic repair of large, mostly paraesophageal hiatal hernias is widely applied, there is a great concern regarding the higher recurrence rate associated with this procedure. In order to reduce this high recurrence rate, several techniques have been developed, mostly applying a mesh prosthesis for hiatal reinforcement. Methods We have recently introduced a new laparoscopic technique in which the hiatal closure is reinforced with the teres ligament. To date 26 patients have been entered into this ongoing prospective study. After the operation patients were called back on a regular basis for symptom evaluation and barium swallow. All 26 patients agreed to undergo barium swallow, with a mean follow-up of 35 months. Results The mean operative time was 115 min. Perioperative morbidity was 11.5%, and conversion to an open procedure was performed in six cases. No mortality was registered. Anatomic recurrence, investigated by barium swallows was observed in four patients (15.3%). Of those four, only one (3.85%) had a symptomatic recurrent paraesophageal hernia; the other three had asymptomtic sliding hernias. In three of the four patients with anatomic recurrence, the diameter of the hiatal hernia was greater than 9 cm at the original operation, and the fourth patient underwent reoperation for recurrent hiatal hernia. No symptomatic recurrence was found in patients with diameter of hiatal hernia between 6 and 9 cm. Conclusions Laparoscopic reinforcement of the hiatal closure with the ligamentum teres is safe and effective treatment for large hiatal hernias. However, it appears that patients with extremely large hiatal hernias are at greater risk of recurrence, and therefore large hernias are not suitable for this new technique.     

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.     

A prospective,randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia

HYPOTHESIS: Large hiatal hernias are prone to disruption, resulting in reherniation, when repaired with simple cruroplasty. The use of mesh may decrease the rate of reherniation in the laparoscopic repair of large hiatal hernias. DESIGN: Prospective, randomized controlled trial. SETTING: University-affiliated private hospital. PATIENTS: Seventy-two individuals undergoing laparoscopic Nissen fundoplication with a hernia defect greater or equal to 8 cm in diameter. INTERVENTION: Nissen fundoplication with posterior cruroplasty (n = 36) vs Nissen fundoplication with posterior cruroplasty and onlay of polytetrafluoroethylene (PTFE) mesh (n = 36). MAIN OUTCOME MEASURES: Recurrences, complications, hospital stay, operative time, and cost. RESULTS: Patients in both groups had similar hospital stays, but the PTFE group had a longer operative time. The cost of the repair was $960 +/- $70 more in the group with the prosthesis. Complications were minor and similar in both groups. There were 8 hernia recurrences (22%) in the primary repair group and none in the PTFE group (P<.006). CONCLUSION: The use of prosthetic reinforcement of cruroplasty in large hiatal hernias may prevent hernia recurrences.     

Is a barium swallow complementary to endoscopy essential in the preoperative assessment of laparoscopic antireflux and hiatal hernia surgery?

Background Barium swallow is considered essential in the preoperative assessment of gastroesophaeal reflux disease and hiatal hernias. The objective of this study was to investigate the effective value of a barium swallow if complementary to the commonly recommended endoscopy before laparoscopic antireflux and hiatal hernia surgery. Methods We prospectively evaluated 40 consecutive patients who were tested with preoperative barium swallow and endoscopy before laparoscopic surgery for gastroesophageal reflux disease and/or symptomatic hiatal hernia. Results regarding the presence and the type of hiatal hernia found by barium swallow and endoscopy were correlated with the intraoperative finding as the reference standard. Results Intraoperative findings revealed 21 axial, 7 paraesophageal, and 12 mixed hiatal hernias. Barium swallow and endoscopy allowed the diagnosis of hiatal hernia in 75% and 97.5%, respectively (p = 0.003). The correct classification of hiatal hernia was confirmed in 50% by barium swallow and 80% by endoscopy (p = 0.005). Conclusions Although barium swallow is recommended as an important diagnostic tool in the workup before surgical antireflux and hiatal hernia therapy, our results suggest that if mandatory endoscopy is performed preoperatively, a barium swallow does not provide any further essential information. It seems that barium swallow can be omitted as a basic diagnostic test before primary laparoscopic antireflux and hiatal hernia surgery.     

Laparoscopic repair of incarcerated paraesophageal hernias

Paraesophageal hernias comprise only 2–5% of all hiatal hernias, yet unlike the more common sliding hiatal hernia, paraesophageal hernias are prone to undergo volvulus, with obstruction, ischemia, and gangrenous perforation. Due to their propensity toward calamitous complications, they must be recognized and repaired as expeditiously as possible. Traditionally these hernias have been repaired by either an open transabdominal or an open transthoracic approach. Laparoscopic repair with Nissen fundoplication has already been successfully applied to the repair of the more common sliding hiatal hernia. Described here is the laparoscopic repair of two paraesophageal hernias. The merit of an anti-reflux procedure as part of this repair is discussed.     

Importance of dissection of the hernial sac in laparoscopic surgery for large hiatal hernias.

HYPOTHESIS: Laparoscopic repair of large hiatal hernia is an appropriate management strategy. DESIGN: A prospective patient series. SETTING: A university teaching hospital. PATIENTS: All patients with hiatal hernias 10 cm or greater in diameter repaired laparoscopically between February 1, 1992, and September 30, 1998. INTERVENTIONS: Two operative strategies were used for laparoscopic repair: the first, which was used until early 1996, entailed initial esophageal dissection while leaving the sac in the mediastinum. The second involved preliminary dissection of the hernial sac from the mediastinum before dissecting the esophagus. MAIN OUTCOME MEASURES: Successful completion of the procedure using a laparoscopic technique, postoperative complication rate, reoperation rate, and clinical outcome. RESULTS: Eighty-six patients with a large hiatal hernia underwent attempted repair using laparoscopic methods. The median age was 63 years (range, 30-91 years), and 45 patients (52%) were women. There were 30 sliding, 10 rolling, and 46 mixed hiatal hernias. Operating times ranged from 48 to 240 minutes (median, 90 minutes), and 20 procedures (23%) were converted to an open operation. Conversion was significantly more common in the first half of our experience (16 [40%] of 40 patients vs 4 [9%] of 46 patients) before the operative strategy was changed. Esophageal-lengthening procedures were not carried out for any patient. At follow-up of a median of 2 years, 1 patient has moderate dysphagia, 4 patients have reflux symptoms, and 1 patient has undergone further surgery for a recurrent paraesophageal hernia. An overall satisfactory outcome was achieved in 81 patients (94%). CONCLUSIONS: Large hiatal hernias can be treated effectively laparoscopically. Dissecting the sac fully from the mediastinum before dissecting the esophagus helps to safely mobilize the esophagus, and we think changing to this strategy is the main reason for the improved laparoscopic success rate reported in the latter half of this series.     

Laparoscopic repair of esophageal hiatal hernia

Hiatal hernias are usually classified into three distinct types: type I, sliding hernia; type II, paraesophageal hernia; and type III, a combination of type I and II hernias. Presentation of type I hernia is so-called reflux symptoms, in contrast with the symptoms associated with mechanical obstruction of the herniated stomach in type II and III hernias. Surgical indications for type I hernia depend upon the severity of esophagitis. In type II and III hernias, severe symptoms and complications represent the chief indications for repair. Totally intrathoracic stomach hernias generally present such a risk of volvulus, strangulation, and perforation that surgery is indicated even in asymptomatic and uncomplicated cases. Although the pathophysiology is different, the Nissen procedure is the surgical procedure of choice for both types of hiatal hernia. Since the first report in 1993, the laparoscopic Nissen procedure has gained wide acceptance. We have so far experienced 26 cases of hiatal hernia, 18 of type I and 8 of type II and III hernias. We used the laparoscopic Nissen procedure in all cases. There were no conversions to the open procedure. Hiatal hernia recurred only in one case with a short esophagus preoperatively. The laparoscopic Nissen procedure is here to stay for the repair of hiatal hernias regardless of their type.     

Laparoscopic Repair of Hiatal Hernia After Esophagectomy

Background

Herniation of abdominal contents via the diaphragmatic hiatus is a potentially life-threatening complication of esophagectomy. Mounting evidence suggests that hiatal hernias are more common following minimally invasive esophagectomy. Therefore, post-esophagectomy hiatal hernia and its treatment bear increasing significance.

Methods

We retrospectively reviewed the records of five patients with hiatal hernia following esophagectomy over a 5-year period.

Results

Successful laparoscopic reduction of a post-esophagectomy hiatal hernia was done without mesh reinforcement in three patients. One patient underwent mesh reinforcement. One patient was found to have carcinomatosis upon laparoscopic inspection, and repair of the hiatal hernia was abandoned. There were no perioperative deaths or complications. One patient developed a recurrent hiatal hernia 14 months after repair of the initial hiatal hernia. Patients were discharged within a mean of 1.75 days after surgical repair.

Discussion

We have successfully used laparoscopy to treat hiatal hernias after esophagectomy. The benefits conferred by laparoscopy, including better visualization of the right gastroepiploic artery supplying the gastric conduit, minimally invasive evaluation of the field for metastasis, and shorter recovery time, make it our favored approach. Here, we describe our experience with hiatal hernia following esophagectomy and our operative technique.     

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 large paraesophageal hiatal hernia

BACKGROUND: The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias. METHODS: Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or type III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function, operative techniques, postoperative symptomatology, and complications were analyzed. RESULTS: Laparoscopic hernia repair and Nissen fundoplication was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 to 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obstruction in 1. Two patients died within 30 days (5.4%), 1 from delayed splenic bleeding and 1 from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven patients (87.1%) were improved. Four patients (12.9%) required early postoperative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 patients (12.9%). Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%). CONCLUSIONS: Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach.     

Giant paraesophageal hernia repair: Technical pearls

The optimal operative management of giant paraesophageal hiatal hernias continues to evolve, with recent series reporting promising results with minimally invasive approaches. The laparoscopic repair of a giant paraesophageal hernia is one of the more challenging cases a minimally invasive surgeon may perform. Our technical approach to this procedure involves a consistent emphasis on several key operative points: circumferential sac dissection with maintenance of crural integrity; extensive mediastinal esophageal dissection; crural closure with pledgeted sutures; wedge Collis gastroplasty for shortened esophagus; 3-stitch fundoplication incorporating esophageal tissue with each bite; additional sutures securing the top of the fundoplication to the crura; and biologic mesh buttressing. We believe that diligence paid toward these key steps permits laparoscopic giant paraesophageal hiatal hernia repair to be performed with similar outcomes as the open approach while avoiding the morbidity of thoracotomy or laparotomy.     

腹腔镜Ⅲ、Ⅳ型食管裂孔疝修补术54例临床分析

目的 分析腹腔镜手术治疗Ⅲ、Ⅳ型食管裂孔疝的方法和疗效.方法 回顾性分析2014年1月至2021年1月东南大学附属中大医院普外科收治的54例行腹腔镜手术治疗的Ⅲ、Ⅳ型食管裂孔疝病人的临床资料,手术方式为食管裂孔疝修补术+胃底折叠术.随访观察术后疗效及并发症发生情况.结果 Ⅲ、Ⅳ型食管裂孔疝54例,包括Ⅲ型食管裂孔疝33...     

Transthoracic induction of a hiatal hernia in domestic swine

Background: With the common performance of laparoscopic Nissen fundoplication for gastroesophageal reflux disease, there is renewed interest in the pathophysiology and potential histologic consequences of hiatal hernias. However, in vivo model exists that both reliably reproduces the hiatal hernia and is amenable to subsequent laparoscopic repair. Methods: A transthoracic approach was used to induce a hiatal hernia surgically in female James pigs (50–160 kg; n= 5). Results: Hiatal hernias were successfully induced in all pigs and verified with barium swallow, endoscopy, and/or laparoscopy. Laparoscopic reduction and Nissen fundoplication were subsequently completed on each animal on postoperative day 30. One postoperative death occurred on postoperative day 4 after thoracotomy. Conclusions: We describe the induction of a hiatal hernia via a transthoracic approach in domestic swine. The hiatal hernia is amenable to subsequent laparoscopic repair, enabling surgeons to acquire the technical skills required to correct this defect in the laboratory. To our knowledge, this is the first report of a reproducible model of a transthoracically induced hiatal hernia that allows subsequent laparoscopic repair. We suggest that in addition to refinement of surgical skills, our model may provide new information to researchers regarding the potential indications for antireflux procedures, as well as the natural history and appropriate management of hiatal hernias.     

Giant hiatal hernias: direct hiatus closure has an acceptable recurrence rate

The purpose of this retrospective study was to analyze our results after laparoscopic repair of giant hiatal hernias with direct closure of the hiatus, since the reports document a radiological recurrence rate as high as 42%. Various studies have shown that laparoscopic hernia repair is safe and effective, and carries a lower morbidity than the open approach, but the high recurrence rates still being reported (ranging from 10 to 42%) have prompted many authors to recommend using a prosthesis. This is a report on the follow-up of 38 patients with type III and IV hiatal hernia who underwent laparoscopic repair with direct hiatal closure without the aid of meshes. From January 2000 to March 2010, 38 patients with III and IV hiatal hernia were treated at the Surgery Division of Cisanello Hospital in Pisa. Data were collected retrospectively and included demographics, preoperative symptoms, radiographic and endoscopic findings, intraoperative and postoperative complications, postoperative symptoms, barium X-ray and follow-up by medical examination and symptoms questionnaire. The sample included 12 males and 26 females, between 36 and 83 years (median age 62) with 26 type III (68.4%) and 12 type IV (31.6%) hernias. There were no conversions to laparotomy and no intraoperative or postoperative mortality. A 360° Nissen fundoplication was performed in 22 patients (57.9%) and a 270° Toupet fundoplication in 16 patients (42.1%). One patient had intraoperative complications (2.6%), and postoperative complications occurred in another three (7.9%). The follow-up was complete in all patients and ranged from 12 to 88 months (median 49 months). Barium swallow was performed in all patients and recurrence was found in five patients (13.1%); three of these patients (7.9%) were asymptomatic, while two (5.2%) were reoperated. All 38 patients' symptoms improved. Judging from our data, the recurrence rate after laparoscopic giant hiatal hernia repair with direct hiatal closure can be lowered by complying with several crucial surgical principles, e.g., complete sac excision and appropriate crural closure, adequate esophageal lengthening, and the addition of an antireflux procedure and a gastropexy. We recorded a radiological recurrence rate of 13.1% (5/38) and patient satisfaction in our series was quite high (92%). Based on these findings, the laparoscopic treatment of giant hernias with direct hiatal closure seems to be a safe and effective procedure.     

Laparoscopic management of giant paraesophageal herniation

BACKGROUND: Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparoscopy for repair of "giant" paraesophageal hernias (gPH). METHODS: Since July 1993, we have accomplished laparoscopic repair of paraesophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had classic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true parahiatal hernias. None had gastric incarceration. Median age was 53 years and 28 of 60 (47%) were women. Chest pain and dysphagia were primary complaints from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were obtained on 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Principles of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; Toupet, 18) to "pexy" the stomach within the abdomen and to control postoperative reflux. RESULTS: Mean operative time was 202+/-81 minutes. Conversion to "open" repair was required in 6 patients (iatrogenic esophageal injury in 2 patients and difficult hernia sac dissection in 4 patients). One postoperative mortality occurred as a result of sepsis and multiorgan failure after an intraoperative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoperative symptoms have been relieved in all but 3 patients. Reoperation for recurrent paraesophageal herniation has been required in these latter 3 patients. CONCLUSIONS: Although technically challenging, laparoscopic repair of paraesophageal hiatal hernias is a viable alternative to "open" surgical approaches. Control of the herniation and the patient's symptoms are equivalent and hospitalization and return to full activity are shorter.     

Anterior gastropexy may reduce the recurrence rate after laparoscopic paraesophageal hernia repair

Background: Although laparoscopic repair of type 3 paraesophageal hernias is safe and results in symptomatic relief, recent data have questioned the anatomic integrity of the laparoscopic approach. The reports document an asymptomatic recurrence rate as high as 42% with radiologic follow-up evaluation for type 3 paraesophageal hernias repaired laparoscopically. This disturbingly high recurrence rate has prompted the addition of an anterior gastropexy to our standard laparoscopic paraesophageal hernia repair. Methods: A prospective series of 28 patients underwent laparoscopic repair of large type 3 hiatal hernias between July 2000 and January 2002 at the Cleveland Clinic Foundation by one surgeon. All the patients underwent reduction of the hernia, sac excision, crural repair, antireflux procedure, and anterior gastropexy. They all had a video esophagram 24 h after surgery, then at 3-, 6-, and 12-month follow-up visits and annually thereafter. Symptomatic outcomes were assessed with a standard questionnaire at each follow-up visit. Results: In this study, 21 women and 7 men with a mean age of 67 years (range, 35–82 years) underwent successful laparoscopic paraesophageal hernia repair. The mean operative time was 146 min (range, 101–186 min), and the average blood loss was 71 ml (range, 10–200 ml). One intraoperative complication occurred: A small esophageal mucosal tear occurred during esophageal dissection and was repaired laparoscopically. At 24 h, upper gastrointestinal examination identified no leaks. At this writing, all the patients have undergone video esophagram at a 3-month follow-up visit. All were asymptomatic and all examinations were normal. Of the 28 patients, 27 have undergone follow-up assessment at 6 months. At this writing, all the patients have undergone video esophagram at 3, 6, and 12 months follow up visits. All were asymptomatic and all examinations were normal. Ten patients have completed 2 year follow up barium swallows with no recurrences. Conclusions: With up to 2 years of follow-up evaluation, the addition of an anterior gastropexy to the laparoscopic repair of type 3 hiatal hernias resulted in no recurrences. These encouraging results necessitate further follow-up evaluation to document the long-term effects of anterior gastropexy in reducing postoperative recurrence after laparoscopic repair of paraesophageal hernias.     

Are Surgisis biomeshes effective in reducing recurrences after laparoscopic repair of large hiatal hernias?

Prosthetic repair is frequently advocated after repair of large hiatal hernias, and biomeshes have been proposed to help reduce the high recurrence rate. All patients undergoing laparoscopic repair of primary or recurrent large hiatal hernia, and with intraoperative finding of weak diaphragmatic pillars, as judged by the surgeon, were included, from June 2004 to July 2005, in a prospective observational study. In these patients, Surgisis biomeshes were employed to assist the repair. Six patients (4 for primary and 2 for recurrent hernia) received biomesh hiatoplasty. Four had mild dysphagia at 1 month that disappeared at the next follow-up. Three had slow radiologic transit through the esophagogastric junction, still present in 1 patient at 1 year. One patient had hernia recurrence 6 months after surgery and 2 other patients had radiologic recurrence of a small hernia at 1-year follow-up; in all 3, the recurrence was small and asymptomatic and none were reoperated. The short-term recurrence rate using biomesh for the laparoscopic repair of large hiatal hernias in patients with weak diaphragmatic pillars was high at 50%. Postoperative morbidity and mesh-related complications were almost absent. Biomeshes can be safely used as on lay reinforcement in hiatoplasty, but do not reduce the hiatal recurrence rate.     

"True" parahiatal hernia: a rare entity radiologic presentation and clinical management

BACKGROUND: True parahiatal diaphragmatic hernias are rare entities that are sparsely accounted for in the literature. The current report is intended to depict the clinical profile and assess the feasibility of laparoscopic repair of parahiatal hernias. METHODS: We conducted a retrospective review of all patients diagnosed and treated for parahiatal hernias. Clinical presentation and radiological assessment, as well as operative findings and repair, are discussed. RESULTS: Of the 917 laparoscopic hiatal hernia repairs, 2 (0.2%) patients were identified with a parahiatal hernia. The presenting symptoms and preoperative testing were similar to those with more common paraesophageal hernias. Laparoscopic repair was successful in repairing the diaphragmatic defect and alleviating symptoms up to 4 years postoperatively. CONCLUSIONS: Parahiatal hernias of the diaphragm appear to be rare primary diaphragmatic defects. The clinical presentation of parahiatal hernias is often indistinguishable from the more common paraesophageal pathology. Laparoscopic repair of this rare entity can be safely and successfully accomplished in conjunction with antireflux surgical interventions when indicated.     

Laparoscopic management of giant hiatal hernia: factors influencing long-term outcome

Background The laparoscopic management of large hiatal hernias still is controversial. Recent studies have presented a high recurrence rate. Methods In this study, 65 patients underwent elective laparoscopic repair of large hiatal hernia. A short esophagus was diagnosed in 13 cases. A primary closure of the hiatal defect was performed in 14 cases. “Tension-free” repair using a mesh was performed in 37 cases, and 14 patients underwent a Collis–Nissen gastroplasty. For the last 38 patients in the series, an intraoperative endoscopy was performed to identify the esophagogastric junction. Results There was no mortality, no conversions to open surgery, and no intraoperative complications. A recurrent hernia was present in 23 of the 77 patients (30%). The recurrence rate was 77% when a direct suture was used and 35% when a mesh was used (p < 0.05). No recurrences were observed in the patients treated with the Collis–Nissen technique, but in one case, perforation of the distal esophagus developed 3 weeks after surgery. The multivariate analysis showed that recurrences are statistically correlated with the type of hiatal hernia and surgical technique. Conclusions To reduce recurrences after laparoscopic management of large hiatal hernias, it is essential to identify all cases of short esophagus using intraoperative endoscopy and to perform a Collis–Nissen procedure in such cases.     

Prevalence of hiatal hernia in the morbidly obese

BackgroundMorbidly obese patients commonly have gastroesophageal reflux (GERD) and associated hiatal hernias. As such, some surgeons routinely perform a concomitant hiatal hernia repair during bariatric surgery. However, the intraoperative inspection for a hiatal hernia based on laparoscopic visualization can be misleading. The aim of this study was to assess the prevalence of hiatal hernias in morbidly obese patients based on preoperative upper gastrointestinal (GI) contrast study.MethodsData on 181 patients who underwent routine upper GI contrast study as part of a preoperative workup for bariatric surgery were reviewed. The upper GI studies were examined for the presence of hiatal hernias and GERD. Hiatal hernias were categorized by size as small (≤2 cm), moderate (2–5 cm), or large (>5 cm). GERD was based on radiologic evidence and categorized as mild, moderate, or severe.ResultsThe mean age of the cohort was 44 years, with a mean body mass index of 43 kg/m². Of the 181 patients overall, based on the upper GI contrast study, the prevalence of hiatal hernia was 37.0% and of GERD was 39.8%; the prevalence of moderate or large hiatal hernia was 4.4%, and the prevalence of moderate or severe GERD was 13.3%.ConclusionsBased on upper GI contrast study, we identified the presence of a hiatal hernia in nearly 40% of morbidly obese patients. The results from this study suggest that surgeons should evaluate the morbidly obese patient for the presence of hiatal hernias and perform concomitant repair at the time of the bariatric procedure, particularly in patients undergoing gastric banding and sleeve gastrectomy, while less so in the gastric bypass patient.