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.     

Incidence of Delayed Gastric Emptying Associated with Revisional Laparoscopic Paraesophageal Hernia Repair

Background

Over the past 15 years, laparoscopic repair of primary paraesophageal hernias (PEH) has become the preferred operative approach. Today, more surgeons are approaching recurrent PEHs laparoscopically, though few studies exist on the long-term results of these revisional operations, particularly regarding the incidence of postoperative delayed gastric emptying (DGE).

Methods

A retrospective review was conducted of all laparoscopic repairs for recurrent PEH done by three surgeons at a single institution from 2003 to 2011. Data collected included age, sex, weight, BMI, pre- and postoperative symptoms, and operative data, but our primary focus was on those patients with pre- and postoperative delayed gastric emptying ultimately requiring operative intervention.

Results

Of 284 patients who underwent laparoscopic PEH repair, 91 (32 %) were performed for recurrent PEH. A sleeve gastrectomy was performed in ten of these patients (11 %) for concomitant morbid obesity which were excluded from our study group, leaving 81 study patients. The mean age was 56 years, and mean BMI was 30. All cases were completed laparoscopically; in 45 (56 %) either a partial or complete fundoplication was performed, and in 68 (84 %) a percutaneous gastrostomy tube (PEG) was placed at the time of revision. Sixty-eight patients underwent repair of a first recurrence, of which 8 (12 %) ultimately required a gastric emptying procedure to alleviate symptoms of DGE. There were nine patients who had a second recurrence repaired, and six (66 %) progressed to a gastric emptying procedure. Finally, of the four patients who had a third recurrence repaired, three (75 %) eventually needed a gastric emptying procedure.

Conclusion

While the incidence of DGE associated with initial PEH repair is low, DGE is a significantly more common finding in patients requiring reoperation for recurrent PEH. This risk increases significantly with repair of each subsequent recurrence. Our data suggest that DGE should be anticipated and patients counseled of the ramifications of this problem preoperatively. Surgeons performing revisional PEH surgery should preemptively develop protocols for the postoperative management of DGE from the time of operation.     

Early results of the use of acellular dermal allograft in type III paraesophageal hernia repair.

BACKGROUND: Type III paraesophageal hernias are diaphragmatic defects with the risk of serious complications. High recurrence rates associated with primary suture repair are significantly improved with the use of a tension-free repair with prosthetic mesh. However, mesh in the hiatus is associated with multiple complications. A bio-engineered material from donated human tissue offers an attractive alternative material for hernia repair. This report is on the first series of laparoscopic type III paraesophageal hernia repairs with acellular dermal allografts (Allo-Derm, Lifecell Corporation, Branchburg, NJ) in 11 patients with follow-up evaluation. METHODS: From August 2003 to June 2004, 11 patients underwent laparoscopic repair of type III paraesophageal hernias with acellular dermal allografts. Patients were evaluated postoperatively with a symptoms questionnaire and barium esophagram. RESULTS: All patients were available for follow-up; however, 2 refused a barium esophagram. Average length of hospital stay was 3 days. Follow-up evaluation was at a mean interval of 1 year. Postoperatively, 9 of 11 patients reported no symptoms. Barium esophagram revealed one recurrence in an asymptomatic patient. CONCLUSION: Type III paraesophageal hernia can be laparoscopically repaired successfully with acellular dermal allografts.     

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.     

Long-term outcome of laparoscopic repair of paraesophageal hernia

Background

It has been reported that the laparoscopic repair of paraesophageal hernias is associated with higher complication and recurrence rates than the open methods of repair.

Methods

We identified 136 consecutive patients who underwent laparoscopic repair of a paraesophageal hernia between 1993 and 1999. Patient demographics and symptom scores for regurgitation, heartburn, chest pain, and dysphagia at presentation and at last follow-up were recorded (0=none, 1=mild, 2=moderate, 3=severe). The operative records were reviewed, and early and late complications were noted. Only patients with a follow-up of 1 were included in the analysis.

Results

The median age was 64 years, and there was a female preponderance (1.8∶1). Most patients had some medical comorbidity; the American Society of Anesthesiologists (ASA) scores were <2 in eight patients and ≥2 in 117 patients. Three laparoscopic operations were converted to open procedures. There were nine intraoperative complications, five early complications, and three related deaths (morbidity and mortality rates of 10.2% and 2.2%, respectively). Follow-up data were available for 83 patients (66%), and the mean follow-up time was 40 months (range, 12–82). The percentage of patients experiencing chest pain, dysphagia, heartburn, and regurgitation in the moderate to severe range dropped from a range of 34–47% to 5–7% (p<0.05). Three patients underwent repeat laparoscopic repair for symptomatic recurrence.

Conclusion

The laparoscopic repair of paraesophageal hernias provides excellent long-term symptomatic relief in the majority of patients and has a low rate of symptomatic recurrence. The complication and death rates may be related in part to the higher incidence of comorbidities in this somewhat elderly patient population.     

Laparoscopic Repair of Paraesophageal Hernias

Background and Objectives:

Laparoscopy has quickly become the standard surgical approach to repair paraesophageal hernias. Although many centers routinely perform this procedure, relatively high recurrence rates have led many surgeons to question this approach. We sought to evaluate outcomes in our cohort of patients with an emphasis on recurrence rates and symptom improvement and their correlation with true radiologic recurrence seen on contrast imaging.

Methods:

We retrospectively identified 126 consecutive patients who underwent laparoscopic repair of a large paraesophageal hernia between 2000 and 2010. Clinical outcomes were reviewed, and data were collected regarding operative details, perioperative and postoperative complications, symptoms, and follow-up imaging. Radiologic evidence of any size hiatal hernia was considered to indicate a recurrence.

Results:

There were 95 female and 31 male patients with a mean age (± standard deviation) of 71 ± 14 years. Laparoscopic repair was completed successfully in 120 of 126 patients, with 6 operations converted to open procedures. Crural reinforcement with mesh was performed in 79% of patients, and 11% underwent a Collis gastroplasty. Fundoplications were performed in 90% of patients: Nissen (112), Dor (1), and Toupet (1). Radiographic surveillance, obtained at a mean time interval of 23 months postoperatively, was available in 89 of 126 patients (71%). Radiographic evidence of a recurrence was present in 19 patients (21%). Reoperation was necessary in 6 patients (5%): 5 for symptomatic recurrence (4%) and 1 for dysphagia (1%). The median length of stay was 4 days.

Conclusion:

Laparoscopic paraesophageal hernia repair results in an excellent outcome with a short length of stay when performed at an experienced center. Radiologic recurrence is observed relatively frequently with routine surveillance; however, many of these recurrences are small, and few patients require correction of the recurrence. Furthermore, these small recurrent hernias are often asymptomatic and do not seem to be associated with the same risk of severe complications developing as the initial paraesophageal hernia.     

Experience of laparoscopic paraesophageal hernia repair at a single institution

BackgroundParaesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy.MethodsBetween January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients.ResultsThe average length of the surgery was 125 minutes (range, 51–304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1–14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%.ConclusionsLaparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.     

Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair

Background

Laparoscopic paraesophageal hernia (PEH) repair is associated with an objective recurrence rate exceeding 50 % at 5 years. Minimizing tension is a critical factor in preventing hernia recurrence. This study aimed to evaluate the outcomes of crural relaxing incisions in patients undergoing PEH repair.

Methods

Records were reviewed to identify patients who received a relaxing incision during laparoscopic PEH repair. The patients were followed by chest X-ray and videoesophagram at 3 months and then annually.

Results

From November 2010 to March 2013, 58 patients underwent PEH repair, and 15 patients received a relaxing incision to accomplish crural closure. The median age of the patients was 72 years (range 58–84 years). The relaxing incision was right-sided in 13 patients, left-sided in one patient, and bilateral in one patient. All the procedures were completed laparoscopically and included a fundoplication. Collis gastroplasty for a short esophagus was performed for 40 % of the patients. No major complications occurred. During a median follow-up period of 4 months, one patient had an asymptomatic mildly elevated left hemidiaphragm, and one patient had a trivial recurrent hernia, as shown on esophagogastroduodenoscopy (EGD).

Conclusion

Crural tension likely contributes to the high recurrence rate noted with laparoscopic PEH repair. Relaxing incisions are safe and allow crural approximation. Advanced laparoscopic surgeons should be aware of this option when faced with a large hiatus in a patient with PEH.     

Paraesophageal hernia repair in the emergency setting: is laparoscopy with the addition of a fundoplication the new gold standard?

Background

Laparoscopic repair of paraesophageal hernia (PEH) with fundoplication is currently the preferred elective strategy, but emergent cases are often done open without an anti-reflux (AR) procedure. This study examined PEH repair in elective and urgent/emergent settings and investigated patient characteristic influence on the use of adjunctive techniques, such as AR procedures or gastrostomy tube (GT) placement.

Methods

Utilizing the University HealthSystem Consortium Clinical Database Resource Manager, selected discharge data were retrieved using International Classification of Disease 9 diagnosis codes for PEH and procedure specific codes. Chi-squared and paired t tests were applied (α = 0.05).

Results

Discharge data from October 2010 through June 2014 indicated 7950 patients (≥18 years) underwent PEH surgery, 84.7 % were performed laparoscopically and 15.3 % open. 24.6 % of cases were classified urgent/emergent upon admission, and almost 70 % of these were completed laparoscopically. Open paraesophageal hernia repairs (OHR) represented a higher proportion of urgent/emergent cases but were only 30 % of this total. Laparoscopic paraesophageal hernia repair (LHR) patients were more likely to receive an AR procedure in all situations (54.9 % LHR vs. 26.3 % OHR). Almost 90 % of elective PEH repairs in this cohort were laparoscopic. Elective cases were more commonly associated with AR procedures than emergent cases which frequently incorporated GT placement.

Conclusion

We demonstrate that laparoscopic PEH repair has become accepted in emergent cases. Open PEH repair is often reserved for emergent surgeries and less commonly includes an AR procedure. Laparoscopy with an AR procedure is clearly the standard of care in elective surgery. The decision to perform an open or laparoscopic surgery, with or without adjunctive techniques, may be based more on the physician’s comfort with laparoscopic surgery and surgical practices than the patient’s condition. Long-term follow-up studies are needed to determine the functional outcomes of these strategies.

     

Traitement vidéolaparoscopique des hernies hiatales par roulement

Study aimThe aim of this prospective study was to report the results of videolaparoscopic repair in a series of ten patients with paraesophageal hernia.Patients and methodsFrom January 1982 to September 1998, ten patients (three men and seven women, mean age: 68 years [range: 42–87]) were operated on for paraesophageal hernia. An intrathoracic gastric volvulus was present in four patients, a severe anemia in four and two were asymptomatic. All interventions were performed laparoscopically and included sac resection, crura closure and realization of a posterior gastric valve on 270 degrees.ResultsThere was one irruption of gastric juice in the bronchial tree at the beginning of the anesthesia which required assisted ventilation for 3 days. The mean follow-up was 17.5 months (range: 3–50). There was no postoperative diarrhea and no gas bloat syndrome. Eight patients complained of postoperative dysphagia which disappeared within 6 weeks, except in one patient with esophageal motility disorder postoperatively discovered. None of the patients had postoperative gastroesophageal reflux. A chest X-ray performed after 1 year detected no hernia recurrence in seven patients. There was no recurrent anemia after 6 months.ConclusionThe videolaparoscopic repair of paraesophageal hernias is feasible without any technical difficulties even in aged patients with precarious physical conditions. The results are good with a mean follow-up of 17.5 months.     

Laparoscopic paraesophageal hernia repair has an acceptable recurrence rate

Recent literature has reported as high as a 42 per cent recurrence rate after laparoscopic paraesophageal hernia repair (LPEHR). We report long-term follow-up in a cohort of patients undergoing LPEHR at Vanderbilt University. Thirty-one patients underwent attempted LPEHR between September 1993 and May 2000. Six of 31 patients (19%) were converted to an open procedure and were excluded from the study. All patients had complete excision of the sac, primary closure of the crura, and an antireflux procedure. An Institutional Review Board-approved follow-up barium esophagram was performed at a mean of 25 months postoperatively. Three experienced laparoscopic surgeons (K.S., M.H., and W.R.) collectively reviewed the esophagrams for evidence of recurrence. The mean age of patients was 61 years (range 41-92). There were six males and 19 females. Fifteen of 25 patients (60%) returned for an esophagram. Only one of 15 patients (7%) had a recurrent paraesophageal hernia. However, five of 15 patients (33%) had herniated an intact wrap 2 to 4 cm above the diaphragm. The patient with a true paraesophageal hernia recurrence returned with symptoms of dysphagia. Two of the five patients (40%) with a herniated wrap complained of heartburn, which was controlled with a proton pump inhibitor. All other patients were asymptomatic. Our recurrence rate of true paraesophageal hernias after LPEHR is low (7%) and compares with that reported in the literature for open repairs. However, 33 per cent of the patients in this study were found to have a herniated wrap. Because there is no risk of strangulation we have not operated on any of these patients. LPEHR is our procedure of choice for Type II and III hiatal hernias with good symptom relief and a low true recurrence rate.     

Incisional Hernia Repair of Medium- and Large-Sized Defects: Laparoscopic IPOM Versus Open SUBLAY Technique

Background: Small incisional hernias can be repaired laparoscopically with low morbidity and reasonable recurrence rates. The aim of this study was to compare laparoscopic with open technique in medium- and large-sized defects regarding postoperative complications and recurrence rates.

Methods: Between 2012 and 2016, 102 patients with medium- or large-sized defects according to EHS classification underwent incisional hernia repair. Patients’ characteristics, hernia size and postoperative complications were prospectively recorded. In October 2016, eligible patients were assessed for recurrence.

Results: About 31 patients underwent laparoscopic IPOM and 71 patients open SUBLAY repair. Morbidity rate was significantly lower in IPOM group than in SUBLAY group (19% versus 41%; p?=?.028). Postoperative complications according to Clavien–Dindo classification were significantly lower in the IPOM group (p?=?.021). Duration of surgery (88 versus 114?min; p?=?.009) and length of hospital stay (five versus eight days; p?<?.001) were significantly shorter for IPOM than for SUBLAY. 71 patients were available for follow-up. Recurrence rates showed no significant difference between study groups (13% versus 7%, p?=?.508).

Conclusions: Laparoscopic repair in medium- and large-sized defects is a feasible and safe approach. IPOM compared to SUBLAY significantly reduces postoperative complications and hospital stay; recurrence rates are comparable.     

A single institution experience with Laparoscopic Hernia repair in 791 children

IntroductionThere are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique.MethodsA retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p < 0.05 was considered significant during the analysis.Results791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41).In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically.ConclusionsThe use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.     

Robotic Repair of Giant Paraesophageal Hernias

Background and Objectives:

Giant paraesophageal hernia accounts for 5% of all hiatal hernias, and it is commonly seen in elderly patients with comorbidities. Some series report complication rates up to 28%, recurrence rates between 10% and 25%, and a mortality rate close to 2%. Recently, the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) has shown equivocal benefits when used for elective surgeries, whereas for complex procedures, the benefits appear to be clearer. The purpose of this study is to present our preliminary experience in robotic giant paraesophageal hernia repair.

Methods:

We retrospectively collected data from patients who had a diagnosis of giant paraesophageal hernia and underwent a paraesophageal hernia repair with the da Vinci Surgical System.

Results:

Nineteen patients (12 women [63.1%]) underwent surgery for giant paraesophageal hernia at our center. The mean age was 70.4 ± 13.9 years (range, 40–97 years). The mean American Society of Anesthesiologists score was 2.15. The mean surgical time and hospital length of stay were 184.5 ± 96.2 minutes (range, 96–395 minutes) and 4.3 days (range, 2–22 days), respectively. Nissen fundoplications were performed in 3 cases (15.7%), and 16 patients (84.2%) had mesh placed. Six patients (31.5%) presented with gastric volvulus, and 2 patients had other herniated viscera (colon and duodenum). There were 2 surgery-related complications (10.5%) (1 dysphagia that required dilatation and 1 pleural injury) and 1 conversion to open repair (partial gastric resection). No recurrences or deaths were observed in this series.

Conclusion:

In our experience robotic giant paraesophageal hernia repair is not different from the laparoscopic approach in terms of complications and mortality rate, but it may be associated with lower recurrence rates. However, larger series with longer follow-up are necessary to further substantiate our results.     

Laparoscopic incisional and ventral hernia repair in a district general hospital

IntroductionThe laparoscopic approach to repairing ventral and incisional hernias has gained increasing popularity worldwide. We reviewed the experience of laparoscopic ventral hernia repair at a district general hospital in the UK with particular reference to patients with massive defects (diameter ≥15cm) and the morbidly obese.MethodsA total of 144 patients underwent laparoscopic ventral (incisional or umbilical/paraumbilical) hernia repair between April 2007 and September 2012.ResultsThe prevalence of conversion to open surgery was 2.8%. The prevalence of postoperative complications was 3.5%. Median postoperative follow-up was 30.2 months. A total of 5.6% cases suffered late complications and 2.8% developed recurrence. Thirty-four patients underwent repair of defects ≥10cm in diameter with a prevalence of recurrence of 5.6%. Sixteen patients underwent repair of ‘massive’ incisional hernia (diameter ≥15cm) with a prevalence of recurrence of 12.5%. Sixteen patients with a body mass index (BMI) ≥40kg/m² (range, 40–61kg/m²) underwent laparoscopic repair with a prevalence of recurrence of 6.3% (p>0.05 vs BMI <40kg/m²).ConclusionsLaparoscopic ventral hernia repair can be carried out safely with a low prevalence of recurrence. It may have advantages in morbidly obese patients in whom open repair would represent a significant undertaking. Laparoscopic ventral hernia repair may be used in cases of large and massive hernias, in which the risk of recurrence increases but is comparable with open repair and associated with low morbidity.     

Durability of laparoscopic repair of paraesophageal hernia.

OBJECTIVES: To define a method of primary repair that would minimize hernia recurrence and to report medium-term follow-up of patients who underwent laparoscopic repair of paraesophageal hernia to verify durability of the repair and to assess the effect of inclusion of an antireflux procedure. SUMMARY BACKGROUND DATA: Primary paraesophageal hernia repair was completed laparoscopically in 55 patients. There were five recurrences within 6 months when the sac was not excised (20%). After institution of a technique of total sac excision in 30 subsequent repairs, no early recurrences were observed. METHODS: Inclusion of an antireflux procedure, incidence of subsequent hernia recurrence, dysphagia, and gastroesophageal reflux symptoms were recorded in clinical follow-up of patients who underwent a laparoscopic procedure. RESULTS: Mean length of follow-up was 29 months. Forty-nine patients were available for follow-up, and one patient had died of lung cancer. Mean age at surgery was 68 years. The surgical morbidity rate in elderly patients was no greater than in younger patients. Eleven patients (22%) had symptoms of mild to moderate reflux, and 15 were taking acid-reduction medication for a variety of dyspeptic complaints. All but 2 of these 15 had undergone 360 degrees fundoplication at initial repair. Two patients (4%) had late recurrent hernia, each small, demonstrated by esophagram or endoscopy. CONCLUSIONS: Laparoscopic repair in the medium term appeared durable. The incidence of postsurgical reflux symptoms was unrelated to inclusion of an antireflux procedure. In the absence of motility data, partial fundoplication was preferred, although dysphagia after floppy 360 degrees wrap was rare. With the low morbidity rate of this procedure, correction of symptomatic paraesophageal hernia appears indicated in patients regardless of age.     

Should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach?

Background The most appropriate approach to the repair of large paraesophageal hernias remains controversial. Despite early results of excellent outcomes after laparoscopic repair, recent reports of high recurrence require that this approach be reevaluated.Methods For this study, 60 primary paraesophageal hernias consecutively repaired at one institution from 1990 to 2002 were reviewed. These 25 open transabdominal and 35 laparoscopic repairs were compared for operative, short-, and long-term outcomes on the basis of quality-of -life questionnaires and radiographs.Results No difference in patient characteristics was detected. Laparoscopic repair resulted in lower blood loss, fewer intraoperative complications, and a shorter length of hospital stay. No difference in general or disease-specific quality-of-life was documented. Radiographic follow-up was available for 78% open and 91% laparoscopic repairs, showing anatomic recurrence rates of 44% and 23%, respectively (p = 0.11).Conclusions Laparoscopic repair should remain in the forefront for the management of paraesophageal hernias. However, there is considerable room for improvement in reducing the incidence of recurrence.Supported by an unrestricted educational grant from Tyco Healthcare Canada     

Reoperative laparoscopic paraesophageal herniorrhaphy can produce excellent outcomes

Background  

Patients undergoing laparoscopic paraesophageal herniorrhaphy present with various esophageal and extraesophageal symptoms. Given a recurrence rate of up to 44%, reoperative intervention is necessary on a number of patients. The goal of this study is to determine whether patients proceeding with reoperative laparoscopic paraesophageal herniorrhaphy experienced symptom resolution equal to or better than patients undergoing first-time repair.     

Combined treatment of symptomatic massive paraesophageal hernia in the morbidly obese

Introduction:

Repair of large paraesophageal hernias by itself is associated with high failure rates in the morbidly obese. A surgical approach addressing both giant paraesophageal hernia and morbid obesity has, to our knowledge, not been explored in the surgical literature.

Methods:

A retrospective review of a bariatric surgery database identified patients who underwent simultaneous repair of large type 3 paraesophageal hernias with primary crus closure and Roux-en-Y gastric bypass (RYGB). Operative time, intraoperative and 30-day morbidity, weight loss, resolution of comorbid conditions and use of anti-reflux medication were outcome measures. Integrity of crural closure was studied with a barium swallow.

Results:

Three patients with a mean body mass index of 46kg/m² and mean age of 46 years underwent repair of a large paraesophageal hernia, primary crus closure, and RYGB. Mean operative time was 241 minutes and length of stay was 4 days. There was no intraoperative or 30-day morbidity. One patient required endoscopic balloon dilatation of the gastrojejunostomy. At 12 months, all patients were asymptomatic with excellent weight loss and resolution of comorbidities. Contrast studies showed no recurrence of the hiatal hernia.

Conclusion:

Simultaneous laparoscopic repair of large paraesophageal hernias in the morbidly obese is safe and effective.     

Same-day discharge for pediatric laparoscopic gastrostomy

BackgroundLaparoscopic gastrostomy is a common procedure in children. We developed a same-day discharge (SDD) protocol for laparoscopic button gastrostomy.MethodsWe performed a prospective observational study of children undergoing laparoscopic button gastrostomy and were eligible for SDD from August 2017–September 2019. Patients were eligible if: 1) the family was comfortable with eliminating overnight admission and were suitable candidates for outpatient surgery (absence of major co-morbidities), 2) they were not undergoing additional procedures requiring admission, and 3) they received pre-operative education.ResultsSixty-two patients who underwent laparoscopic button gastrostomy were eligible for SDD. The median age was 2.1 years [IQR 0.9–4.1], and the median weight was 10.5 kg [IQR 7.6–15.5]. Forty-one (66%) were previously nasogastric fed. The median operative time was 22 min [IQR 16–29]. The median time to initiation of feeds was 4.4 h [IQR 3.4–5.5]. Fifty-one (82%) were discharged the same day with a median length of stay of 9 h [IQR 7–10]. Eleven were admitted, most commonly for further teaching. Eleven SDD patients were seen in the emergency room < 30 days at a median 5 days [IQR 3–12] post-operatively, primarily for mechanical complications.ConclusionSame-day discharge following laparoscopic gastrostomy is safe and feasible for select pediatric patients who undergo pre-operative education. The SDD pathway results in a low admission rate and relatively low ER visits.Type of studyProspective Observational Study.Level of EvidenceLevel II.