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     

Evolution and development of surgery for large paraesophageal hiatus hernia

Laparoscopic repair is the standard surgical approach to the problem of large paraesophageal hiatus hernia. It is associated with low risks of morbidity and mortality, although there is a small risk (less than 5%) of a clinically significant recurrent hernia. Various techniques have been proposed to minimise this risk, including esophageal lengthening procedures and mesh reinforcement of the hiatus. Both remain controversial. Radiological outcomes from randomised trials suggest that a reduction in hernia recurrence rates can be achieved with the use of mesh repair, although these trials have not demonstrated any clinically significant benefits for mesh repair. The risk of complications following mesh placement at the esophageal hiatus or an esophageal lengthening procedure needs to be balanced against potential benefits. More work is required to define the optimal approach to repair of large paraesophageal hiatus hernias.     

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.     

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.     

Paraesophageal hernia: surgery problems in emergency

CASE REPORT: It has been demonstrated that paraesophageal hiatal hernia surgical repair can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The Authors report a case of strangulated paraesophageal hiatal hernia occurred in a elderly man and treated with open approach. Eighteen months later, follow up has demonstrated the effectiveness of the repair and the total remission of the symptoms. Recurrences after paraesophageal hiatal hernias repair may decrease with usage of mesh in the hiatus; however uniform criteria for this procedure are lacking. After review of the literature inheriting this uncommon pathology, that present about 5% of the hiatal hernias, no conclusions could be drawn regarding the reliability of the laparoscopic procedure and the necessity for an additional antireflux repair. Moreover, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus cases could not be detected. CONCLUSIONS: Treatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies inherent surgery indications and approach.     

Paraesophageal hernias: operation or observation?

OBJECTIVE: To examine the hypothesis that elective laparoscopic repair should be routinely performed on patients with asymptomatic or minimally symptomatic paraesophageal hernias. SUMMARY BACKGROUND DATA: The management of asymptomatic paraesophageal hernias is a controversial issue. Most surgeons believe that all paraesophageal hernias should be corrected electively on diagnosis, irrespective of symptoms, to prevent the development of complications and avoid the risk of emergency surgery. METHODS: A Markov Monte Carlo decision analytic model was developed to track a hypothetical cohort of patients with asymptomatic or minimally symptomatic paraesophageal hernia and reflect the possible clinical outcomes associated with two treatment strategies: elective laparoscopic paraesophageal hernia repair (ELHR) or watchful waiting (WW). The input variables for ELHR were estimated from a pooled analysis of 20 published studies, while those for WW and emergency surgery were derived from the 1997 HCUP-NIS database and surgical literature published from 1964 to 2000. Outcomes for the two strategies were expressed in quality-adjusted life-years (QALYs). RESULTS: Analysis of the HCUP-NIS database showed that published studies overestimate the mortality of emergency surgery (17% vs. 5.4%). The mortality rate of ELHR was 1.4%. The annual probability of developing acute symptoms requiring emergency surgery with the WW strategy was 1.1%. For patients 65 years of age, ELHR resulted in reduction of 0.13 QALYs (10.78 vs. 10.65) compared with WW. The model predicted that WW was the optimal treatment strategy in 83% of patients and ELHR in the remaining 17%. The model was sensitive only to alterations of the mortality rates of ELHR and emergency surgery. CONCLUSIONS: If ELHR is routinely recommended, it would be more beneficial than WW in fewer than one of five patients. WW is a reasonable alternative for the initial management of patients with asymptomatic or minimally symptomatic paraesophageal hernias, and even if an emergency operation is required, the burden of the procedure is not as severe as was thought in the past.     

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     

Laparoscopic tension-free repair of large paraesophageal hernias

The paraesophageal hernia is an unusual disorder of the esophageal hiatus that may be associated with life-threatening mechanical problems. Elective repair is recommended at the time the condition is diagnosed, and open surgery can be accomplished with a low incidence of complications. The option of performing these repairs through a laparoscopic approach may further reduce morbidity and recovery time associated with surgical intervention. The purpose of this report was to review available options for laparoscopic repair and to present our experience with a tension-free technique for large paraesophageal hernias. Three patients with large diaphragmatic defects had laparoscopic repairs using an expanded polytetrafluorethylene (PTFE) patch secured with intracorporeal suturing techniques. One of these patients also underwent laparoscopic Toupet fundoplication in conjunction with repair of the hernia. In the other two patients, the fundus was secured to the right diaphragmatic crus to reduce the potential for recurrence and minimize postoperative reflux symptoms. All patients underwent successful repair without perioperative complications and had excellent long-term results. Laparoscopic repair of paraesophageal hernias can be accomplished by a number of different reported techniques. The use of a tension-free repair with PTFE may be particularly suitable for large diaphragmatic defects. An antireflux operation may be added selectively depending on clinical circumstances.     

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.     

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.     

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.     

Onlay hiatal reinforcement utilizing human acellular dermal matrix: three case series

Redo laparoscopic fundoplication and laparoscopic repair of large (>5cm) paraesophageal hernias have a high rate of recurrence after primary suture repair of the hiatal defect. As such, the use of mesh prosthesis as an interposition graft or onlay reinforcement is becoming more popular for the repair of larger, more complicated crural defects. We report three cases in which human acellular dermal matrix was used as an onlay reinforcement of the hiatus after primary suture closure. Two patients had large paraesophageal hernias (one type III and one type IV). The third patient became symptomatic after her second laparoscopic antireflux procedure and was found to have recurrent herniation of the fundus into the mediastinum. All three patients underwent successful laparoscopic repair. There were no intraoperative or postoperative complications. All three patients remain symptom free with follow-up ranging from 8 months to 10 months. Acellular dermal matrix appears to be a promising prosthetic for onlay reinforcement of the hiatus during redo laparoscopic fundoplication and repair of large paraesophageal hernias.     

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.     

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.     

Laparoscopic hiatal hernia repair in patients with poor esophageal motility or paraesophageal herniation

Laparoscopic repair for gastroesophageal reflux disease is now an accepted therapy. However, controversy exists with regard to the choice of operation between complete 360-degree Nissen fundoplication versus partial 270-degree Toupe fundoplication. In addition there is some controversy with regard to the proper choice of operation in patients with poor esophageal motility. Another class of hiatal hernia patients are those patients with paraesophageal herniation. Questions regarding the approach to these patients include whether or not to use a reflux procedure at the time of repair and the role of mesh in repair of these large hernias. This retrospective study was undertaken to compare the results of laparoscopic Nissen fundoplication and Toupe fundoplication in patients with both normal and abnormal esophageal motility. In addition the subset of patients with paraesophageal herniation was studied in an effort to ascertain the best surgical approach in these patients. In this study a retrospective analysis was performed on 188 consecutive patients during the period 1995 to 2001. All patients who presented with hiatal hernia surgical problems during this period were included. Endoscopy was performed in all patients with esophageal reflux. Manometry was performed in all patients except those presenting as emergency incarcerations. pH probe testing was performed in those patients in whom it was deemed necessary to establish the diagnosis. Upper gastrointestinal radiographs were used to define anatomy in paraesophageal hernia patients when possible. All patients with esophageal reflux were first treated with a trial of medical therapy. Patients with esophageal reflux and normal esophageal motility underwent 360-degree Nissen fundoplication. Those patients with poor esophageal motility (less than 65 mm of mercury) underwent laparoscopic 270-degree Toupe fundoplication. Patients presenting with paraesophageal herniation underwent laparoscopic repair. When possible esophageal manometry was performed on these patients preoperatively and if normal peristalsis was documented a Nissen fundoplication was performed. If poor esophageal motility was documented before surgery a Toupe fundoplication was performed. Mesh reinforcement of the diaphragmatic hiatus was used if necessary to complete a repair without tension. Patients were followed both by their primary gastroenterologist and their surgeon. Follow-up studies including endoscopy, pH probe, and upper gastrointestinal series were used as necessary in the postoperative period to document any problems as they occurred. Of the 188 patients in the study 141 patients underwent Nissen fundoplication, 21 patients underwent Nissen fundoplication and repair of paraesophageal hernia, 15 underwent Toupe fundoplication, seven underwent Toupe and paraesophageal hernia repair, and four paraesophageal hernia repair alone. One hundred eighty-three patients underwent a laparoscopic operation. Five patients of the 188 underwent an initial open operation-two of these patients because of the size of their paraesophageal hernia. Three of these patients had reoperations of remote operations done years before at other institutions. Twenty-two patients with poor esophageal motility (11.7 %) were included in the study. Fifteen patients required Toupe fundoplication whereas seven patients required Toupe fundoplication and repair of paraesophageal hernias. Mesh repair of paraesophageal hernias was accomplished in ten patients. Patients undergoing Toupe fundoplication had a 13 per cent dysphagia rate less than 4 weeks postoperatively and a 0% dysphagia rate greater than four weeks postoperatively. Patients undergoing Nissen fundoplication had a 16 per cent dysphagia rate less than 4 weeks postoperatively, 2 per cent dysphagia rate greater than 4 weeks postoperatively and no dysphagia at 6 weeks postoperatively. Recurrent symptomatic reflux occurred in 1.4 per cent of Nissen fundoplications and 6.7 per cent of Toupe fundoplications. Of Nissen and paraesophageal repairs 14.2 per cent had reflux and 14.3 per cent of Toupe and paraesophageal repairs had recurrent symptomatic reflux. Overall, complication rate was low. Use of mesh to repair large paraesophageal hernias resulted in a recurrence rate of 0 per cent. There was no instance of infection or bowel fistulization related to the use of mesh. We conclude that laparoscopic Nissen fundoplication in patients with normal esophageal motility is associated with a low rate of dysphagia and a low rate of recurrent reflux. Toupe fundoplication when used in reflux patients with poor esophageal motility is associated with a low rate of dysphagia and an acceptable rate of recurrent reflux. Laparoscop     

Transthoracic repair of an incarcerated diaphragmatic hernia using hexamethylene diisocyanate cross-linked porcine dermal collagen (Permacol)

It is the general surgeon who commonly repairs paraesophageal hernias nowadays, and they are repaired laparoscopically, making the performance of thoracotomy relatively rare. Whether to use prosthetic materials to repair the hiatus is still under debate, as is the question of which material to use, if any. We report a case of a 38-year-old man who had a large, incarcerated paraesophageal hernia. He had a past history of extensive abdominal surgery for exomphalos, which rendered any abdominal surgical approach a high-risk procedure. We therefore decided to proceed with thoracotomy and repair of the hiatus with hexamethylene diisocyanate (HMDI) cross-linked porcine dermal collagen. He made a good recovery with no complications.     

Splenic rupture as a consequence of giant paraesophageal hernia

Elective surgical repair of "giant" paraesophageal hernias is recommended to prevent the potential complications of gastric volvulus, obstruction, and ischemic perforation. We report the unusual complication of splenic capsular laceration and hemorrhagic shock following forceful retching by a patient with an incarcerated paraesophageal hernia.     

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.     

The use of small intestine submucosa in the repair of paraesophageal hernias: initial observations of a new technique

BACKGROUND: Recent reports suggest that when laparoscopy is used to repair paraesophageal hernias recurrence rates reach 20% to 40%. Tension-free hernia closure with synthetic mesh reduces recurrence but occasionally results in esophageal injury. We hypothesized that reinforcement of the hiatal closure with small intestine submucosa (SIS) mesh, in some unusually large hernias, might reduce recurrence rates without causing injury to the esophagus. METHODS: From January 2001 to March 2002 we treated 18 large paraesophageal hernias via a laparoscopic approach. In 9 of the largest hernias (one type II and 8 type III, of which 1 was recurrent) the repair was reinforced with SIS mesh (Surgisis, Cook Surgical) and represent the subjects of this study. Nissen fundoplication with gastropexy was performed in all patients. Clinical follow-up ranged from 3 to 16 months (median 8). Every patient was evaluated with barium esophagram or endoscopy or both 1 to 8 months (median 2) postoperatively. RESULTS: The presenting symptoms were postprandial pain/fullness (9 of 9), heartburn (4 of 9), anemia (4 of 9), dysphagia (3 of 9), regurgitation (3 of 9), and chest pain (3 of 9). One patient died of a hemorrhagic stroke within 30 days of the operation. Postoperatively, presenting symptoms resolved (83%) or improved (17%) in each of the remaining 8 patients. One patient required endoscopic dilation for mild dysphagia. Seven of 8 patients had a normal barium esophagram without evidence of hernia. One morbidly obese (body mass index = 47) patient had a small (2 cm) sliding hiatal hernia postoperatively. There were no other complications, and specifically no perforations or mesh erosions. CONCLUSIONS: These observations suggest that the use of SIS in the repair of paraesophageal hernias is safe and may reduce recurrence. Longer follow-up and a randomized study are needed to validate these results.     

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.