Laparoscopic Paraesophageal Hernia Repair

Background and Objective:

Paraesophageal hernias are uncommon yet potentially lethal conditions. Their repair has now been facilitated by laparoscopic technology. We present a series of 20 patients with paraesophageal hernias repaired laparoscopically.

Methods:

Twenty patients with paraesophageal hernias had laparoscopic repairs. Eighteen patients had primary repair of their hiatal defect. Two required mesh reinforcement. Fifteen patients had a fundoplication procedure performed concomitantly.

Results:

Long-term follow-up is available on 17 patients. There was no in-hospital morbidity or mortality. Average length of stay was 2.3 days. One patient recurred in the immediate postoperative period. There were no other recurrences. The only death in the series occurred in the oldest patient 18 days postoperatively. He had been discharged from the hospital and died of cardiac failure. No patients have had complications from a paraesophageal hernia postoperatively.

Conclusion:

Laparoscopic repair of paraesophageal hernias is possible. Preoperative work-up should include motility evaluation to assess esophageal peristalsis as the majority of these will need a concomitant anti-reflux procedure. This data helps the surgeon to determine whether or not a complete or partial wrap should be done. Repair of the diaphragmatic defect can be accomplished in the majority of patients without the use of prosthetic material with excellent results.     

Simultaneous Paraesophageal Hernia Repair and Gastric Banding

The presence of a hiatal hernia is generally considered a contraindication to gastric banding in the morbidly obese, despite recent reports indicating favorable outcomes following simultaneous repair of sliding hernias and laparoscopic adjustable gastric banding (LAGB). A 66-year-old woman weighing 120 kg (BMI 45) with arterial hypertension and gastroesophageal reflux-related chronic obstructive pulmonary disease underwent repair of a large paraesophageal hernia and LAGB. At 40 months followup, the patient had lost 44% excess body weight (BMI 36) and had no complaints of heartburn, regurgitation or dysphagia. She was no longer hypertensive and her pulmonary condition had improved significantly. Barium swallow at 30 months showed normal anatomy and positioning of the band. Because other minimally traumatic surgical options are lacking, the author believes morbidly obese patients with hiatal hernia should not be denied the advantages of LAGB. Adequate weight reduction, resolution of gastroesophageal reflux and other co-morbidities can be expected if an appropriate surgical technique is used.     

The Laparoscopic Approach to Paraesophageal Hernia Repair

Introduction  

Laparoscopic paraesophageal hernia repair continues to be one of the most challenging procedures facing the minimally invasive surgeon.     

How I Do It: Laparoscopic Paraesophageal Hernia Repair

Introduction

Paraesophageal hernias are usually complex anatomic abnormalities of the upper gastrointestinal tract capable of causing symptoms and complications including death. Furthermore, they affect patients who are usually older and have other comorbidities. Preferred treatment approach has evolved over time, with laparoscopic repair being the current preferred technique as it causes less hemodynamic changes and is better tolerated than open repairs.

Technique

In this report, we describe our technique for laparoscopic paraesophageal hernia repair. The most salient technical aspects of this procedure include reduction of the stomach below the diaphragm, circumferential dissection and excision of the hernia sac, closure of the crural defect with our without the addition of mesh, and fundoplication to prevent reflux.

Conclusion

While this procedure has a low morbidity risk and short hospital stay, anatomic recurrence is frequent even when performed by experienced surgeons.     

Prevalence and Resolution of Anemia with Paraesophageal Hernia Repair

Background

Paraesophageal hernias may produce a variety of clinical sequelae including anemia and esophagogastric ulcerations or erosions. We examined the prevalence of anemia in patients with paraesophageal hernias and frequency of anemia resolution with hernia repair.

Methods

Patients undergoing paraesophageal hernia repairs from July 1996 to September 2010 were included. Data gathered included age, gender, type of hernia, presence of symptomatic anemia, presence of esophagogastric ulcer/erosion, type of repair, and anemia resolution.

Results

One hundred eighty-three patients underwent paraesophageal hernia repair; of these, 68 (37?%) were anemic. Of these anemic patients, 39 (57?%) were symptomatic from their anemia or specifically referred for anemia, and 20 (29?%) had esophagogastric ulceration/erosion. Fifty-eight had documented follow-up. Overall, of these, 35 (60?%) had resolution of their anemia. Seventy percent of symptomatic patients had resolution of their anemia, compared to 48?% of asymptomatic patients (p?=?0.1). Of patients with esophagogastric ulceration/erosion, 85?% were symptomatic and 88?% had resolution of anemia, compared to 50?% of patients without ulceration/erosion (p?=?0.015).

Conclusions

Anemia was a common finding in patients with paraesophageal hernia and most patients were symptomatic because of their anemia. Those patients with esophageal or gastric ulceration/erosion were very likely to have symptomatic anemia, and, interestingly, these patients were more likely to have their anemia resolve with paraesophageal hernia repair.     

Laparoscopic Paraesophageal Hernia Repair. How I do it

Introduction  The approach to paraesophageal hernias has changed radically over the last 15 years, both in terms of indications for the repair and of surgical technique. Discussion  Today we operate mostly on patients who are symptomatic and the laparoscopic repair has replaced in most cases the open approach through either a laparotomy or a thoracotomy. The following describes a step by step approach to the laparoscopic repair of paraesophageal hernia. Presented at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract, San Diego, California, May 17–21, 2008     

Inpatient Mortality Analysis of Paraesophageal Hernia Repair in Octogenarians

Introduction

Paraesophageal hernia repair is often performed in an elderly population. Few studies have evaluated perioperative mortality in this group. We identified predictors of inpatient mortality using a nationally representative sample.

Methods

Patients ≥80 years old undergoing transabdominal paraesophageal hernia repair were identified in the 2005 Nationwide Inpatient Sample. Congenital diaphragmatic defects and traumatic injuries were excluded.

Results

One thousand five discharges (73% female) with mean age 84.7 met inclusion criteria. Mean length of stay was 10.1 days (95% confidence interval 8.9–11.3) with a mortality of 8.2%. Non-elective repair was performed in 43%. For these patients, mortality and mean length of stay (16%; 14.3 days) were increased compared to elective repair (2.5%; 7.0 days, p?<?0.05). Non-elective repair was the sole predictor of inpatient mortality in adjusted analyses (odds ratio 7.1, 95% confidence interval 1.9–26.3, p?<?0.05).

Conclusion

Non-elective repair was associated with a six to sevenfold increase in mortality and longer length of stay. Earlier elective repair of paraesophageal hernia may reduce mortality.     

Paraesophageal Hernia Repair With Partial Longitudinal Gastrectomy in Obese Patients

Background and Objectives:

Treatment of gastroesophageal reflux disease (GERD) with hiatal hernia in obese patients has proven difficult, as studies demonstrate poor symptom control and high failure rates in this patient population. Recent data have shown that incorporating weight loss procedures into the treatment of reflux may improve overall outcomes.

Methods:

We retrospectively reviewed 28 obese and morbidly obese patients who presented from December 2007 through July 2013 with large or recurrent type 3 or 4 paraesophageal hernia. All of the patients underwent combined paraesophageal hernia repair and partial longitudinal gastrectomy. Charts were retrospectively reviewed, and the patients were contacted to determine symptomatic relief.

Results:

Mean preoperative body mass index was 38.1 ± 4.9 kg/m². Anatomic failure of prior fundoplication occurred in 7 patients (25%). The remaining 21 had primary paraesophageal hernia, 3 of which were type 4. Postoperative complications included pulmonary embolism (n = 1), pulmonary decompensation (n = 2), and wound infection (n = 1). Mean hospital stay was 5 ± 3 days. Upper gastrointestinal esophagogram was performed in 21 patients with no immediate recurrence or staple line dehiscence. Mean excess weight loss was 44 ± 25%. All of the patients surveyed experienced near to total resolution of their preoperative symptoms within the first month. At 1 year, symptom scores decreased significantly. At 27 months, however, there was a mild increase in the scores. Return of severe symptoms occurred in 2 patients, both of whom underwent conversion to gastric bypass.

Conclusions:

Combined laparoscopic paraesophageal hernia repair with longitudinal partial gastrectomy offers a safe, feasible approach to the management of large or recurrent paraesophageal hernia in well-selected obese and morbidly obese patients. Short-term results were promising; however, intermediate results showed increasing rates of reflux symptoms that required medical therapy or conversion to gastric bypass.     

Paraesophageal Hernia Repair with Biomesh Does Not Increase Postoperative Dysphagia

Introduction  

Laparoscopic techniques have led to hiatal procedures being performed with less morbidity but higher failure rates. Biologic mesh (biomesh) has been proposed as an alternative to plastic mesh to achieve durable repairs while minimizing stricturing and erosion. This paper documents the lack of significant dysphagia after the placement of biomesh during hiatal hernia repair.