Massive hiatal hernias: the anatomic basis of repair

Management of paraesophageal hiatus hernia: recommendations following a European expert Delphi consensus

AIMS

There is considerable controversy regarding optimal management of patients with paraesophageal hiatus hernia (pHH). This survey aims at identifying recommended strategies for work-up, surgical therapy, and postoperative follow-up using Delphi methodology.

METHODS

We conducted a 2-round, 33-question, web-based Delphi survey on perioperative management (preoperative work-up, surgical procedure and follow-up) of non-revisional, elective pHH among European surgeons with expertise in upper-GI. Responses were graded on a 5-point Likert scale and analyzed using descriptive statistics. Items from the questionnaire were defined as "recommended" or "discouraged" if positive or negative concordance among participants was > 75%. Items with lower concordance levels were labelled "acceptable" (neither recommended nor discouraged).

RESULTS

Seventy-two surgeons with a median (IQR) experience of 23 (14-30) years from 17 European countries participated (response rate 60%). The annual median (IQR) individual and institutional caseload was 25 (15-36) and 40 (28-60) pHH-surgeries, respectively. After Delphi round 2, "recommended" strategies were defined for preoperative work-up (endoscopy), indication for surgery (typical symptoms and/or chronic anemia), surgical dissection (hernia sac dissection and resection, preservation of the vagal nerves, crural fascia and pleura, resection of retrocardial lipoma) and reconstruction (posterior crurorrhaphy with single stitches, lower esophageal sphincter augmentation (Nissen or Toupet), and postoperative follow-up (contrast radiography). In addition, we identified "discouraged" strategies for preoperative work-up (endosonography), and surgical reconstruction (crurorrhaphy with running sutures, tension-free hiatus repair with mesh only). In contrast, many items from the questionnaire including most details of mesh augmentation (indication, material, shape, placement, and fixation technique) were "acceptable".

CONCLUSIONS

This multinational European Delphi survey represents the first expert-led process to identify recommended strategies for the management of pHH. Our work may be useful in clinical practice to guide the diagnostic process, increase procedural consistency and standardization, and to foster collaborative research.

Giant Paraesophageal Hernia With Obstructing Splenic Flexure Mass in the Left Hemithorax

Giant paraesophageal hernias contain greater than fifty percent of the stomach above the diaphragm. Over fifty percent of large bowel obstructions are due to colorectal adenocarcinoma. Here, we present a rare case of a 69-year-old female patient who developed a closed loop colonic obstruction caused by a colonic mass in the distal transverse colon within a giant paraesophageal hernia. We successfully performed emergent paraesophageal hernia reduction and mesh repair with extended right hemicolectomy and ileocolonic anastomosis. Emergent hernia repair via an abdominal approach can be used in this setting.

Simultaneous laparoscopic hiatal hernia repair and pyloroplasty for a type 3 hiatal hernia with post-ESD pyloric stenosis for early gastric cancer

We present a case of early gastric cancer in the pylorus with a type 3 hiatal hernia, which was treated by endoscopic submucosal dissection (ESD). A 70-year-old man was referred to our hospital with a hiatal hernia. Endoscopy revealed early gastric cancer, and we performed an ESD adaptation at the pylorus. The ESD was successful, but post-ESD pyloric stenosis occurred. Symptoms of hiatal hernia worsened because of the pyloric stenosis. Laparoscopic hiatal hernia repair with Toupet fundoplication and Heineke-Mikulicz pyloroplasty was simultaneously performed. The postoperative course was good, and follow-up after discharge was uneventful. To our knowledge, there have been no reports in which laparoscopic hiatal hernia repair, fundoplication, and pyloroplasty were simultaneously performed for a substantial hiatal hernia with post-ESD pyloric stenosis.

Manometric Esophageal Length to Height (MELH) Ratio Predicts Hiatal Hernia Recurrence

INTRODUCTION

The shortened esophagus is poorly defined and is determined intraoperatively, as there exists no objective test to identify a shortened esophagus before surgical hiatal hernia repair. We devised a unique manometric esophageal length to height (MELH) ratio to define the presence of a shortened esophagus and examined the role of esophageal length in hiatal hernia recurrence.

PATIENTS AND METHODS

A retrospective review identified 254 patients with hiatal hernia who underwent preoperative esophageal manometry and either an open hernia repair with Collis gastroplasty and fundoplication (with Collis) or laparoscopic repair and fundoplication without Collis gastroplasty (without Collis) from 2005-2016. The MELH ratio was calculated by measuring the upper to lower esophageal sphincter distance divided by the patient's height.

RESULTS

Of 245 patients, 157 underwent repair with Collis, while 97 underwent repair without Collis. The Collis group had a shorter manometric esophageal length (20.2 vs. 22.4 cm, P<0.001) and lower MELH (0.12 vs. 0.13, P<0.001). The Collis group had fewer hernia recurrences (18% vs. 55%, log-rank P<0.001) and fewer reoperations for recurrence (0% vs. 10%, log-rank P<0.001) at 5 years. A 33% decrease in risk of hernia recurrence was seen for every 0.01 U increment in MELH ratio (hazard ratio: 0.67; 95% confidence interval: 0.55-0.83, P<0.001) while repair without Collis (hazard ratio: 6.1; 95% confidence interval: 3.2-11.7, P<0.001) was associated with increased risk of hernia recurrence.

CONCLUSION

MELH ratio is an objective predictor of a shortened esophagus preoperatively. Lower MELH is associated with increased risk of recurrence and the risk associated with shortened esophagus can be mitigated with an esophageal lengthening procedure such as Collis gastroplasty.

Robotic Fundoplication for Large Paraesophageal Hiatal Hernias

Purpose:

Laparoscopic fundoplication is now a cornerstone in the treatment of gastro-esophageal reflux disease (GERD) with sliding hernia. The best outcomes are achieved in those patients who have some response to medical treatment compared to those who do not. Robotic fundoplication is considered a novel approach in treating GERD with large paraesophageal hiatal hernias. Our goal was to examine the feasibility of this technique.

Methods:

Seventy patients (23 males and 47 females) with mean age 64 y old (22–92), preoperatively diagnosed with a large paraesophageal hiatal hernia, were treated with a robotic approach. Biosynthetic tissue absorbable mesh was applied for hiatal closure reinforcement. Fifty-eight patients underwent total fundoplication, 11 patients had partial fundoplication, and one patient had a Collis-Nissen fundoplication for acquired short esophagus.

Results:

All procedures were completed robotically, without laparoscopic or open conversion. Mean operative time was 223 min (180–360). Mean length of stay was 38 h (24–96). Median follow-up was 29 mo (7–51). Moderate postoperative dysphagia was noted in eight patients, all of which resolved after 3 mo without esophageal dilation. No mesh-related complications were detected. There were six hernia recurrences. Four patients were treated with redo-robotic fundoplication, and two were treated medically.

Conclusions:

The success of robotic fundoplication depends on adhering to a few important technical principles. In our experience, the robotic surgical treatment of gastroesophageal reflux disease with large paraesophageal hernias may afford the surgeon increased dexterity and is feasible with comparable outcomes compared with traditional laparoscopic approaches.

Post-operative giant hiatal hernia: A single center experience

To verify the results of the treatment of post-operative giant hiatal hernia (POGH).The POGH becomes each time more frequent after surgical treatment of the gastroesophageal reflux.Fifteen patients (6 females and 9 males; 43.66 ± 5.05 years old; BMI 22.13 ± 1.92) were referred to our Service, for surgical treatment of a type III POGH 30.4 ± 1.76 months after treatment of gastroesophageal reflux disease. The need for a reoperation was determined mainly by dysphagia.Reoperation was completed laparoscopically in all patients and the mean postoperative hospital stay was 3.2 ± 1.2 days (range, 1-6 days). Mortality was 0% and there were not postoperative complications. They became asymptomatic along follow-up of 2.86 ± 1.40 years. Around 1 year from the procedure, patients were submitted to control exams and barium esophagogram revealed well positioned esophago-gastric junction and signs of intact fundoplicature, the same observation having been done at esophageal endoscopy. Esophageal manometry showed preserved peristaltism, increase of resting pressure and extension of the intra-abdominal LES and significant raise of amplitude of deglutition waves at distal third of the esophagus. No reflux was observed at post-operative 24-hour pH testing.The corrective surgery of POGH can often be completed laparoscopically in experienced hands. Successful results can be obtained performing reduction of the hernia, sac excision, crural repair, anti-reflux procedure and long anterior gastropexy.

A comparison between Belsey Mark IV and laparoscopic Nissen fundoplication in patients with large paraesophageal hernia

OBJECTIVES

Laparoscopic Nissen fundoplication is the most commonly performed operation for the repair of large hiatal hernias. We compared outcomes between the Belsey Mark IV fundoplication and the laparoscopic Nissen fundoplication.

METHODS

A retrospective review was performed over a 10-year period on patients who had repair of large paraesophageal hernia. Patients who received the Belsey Mark IV (n = 118) were matched 1 to 1, by year of surgery, gender, and age, with patients who received laparoscopic Nissen fundoplication. We compared these 2 groups, examining recurrence, need for reoperation, perioperative outcomes, and symptomatic follow-up as defined by the Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire.

RESULTS

Recurrence rates were similar between patients who had a Belsey Mark IV and laparoscopic Nissen fundoplication (8.4% vs 16.1%, P = .11). However, the esophageal leak rate was higher in patients who received a laparoscopic Nissen fundoplication compared with the Belsey Mark IV (6.8% vs 0%, respectively, P = .006), and patients who received a laparoscopic Nissen fundoplication had higher rates of reoperation (9.3% vs 2.5%, respectively, P = .05). Gastroesophageal Reflux Disease-Health Related Quality of Life symptom scores were similar between groups with symptoms in laparoscopic Nissen fundoplication and Belsey Mark IV, being excellent (74.4% vs 81.4%), good (9.3% vs 7.0%), fair (9.3% vs 0), and poor (7.0% vs 11.6%), respectively (P = .52).

CONCLUSIONS

Laparoscopic Nissen fundoplication for large paraesophageal hernias was associated with an increased incidence of leak and reoperation when compared with Belsey fundoplication. Belsey Mark IV fundoplication should be considered when deciding on what operation to perform in patients with large paraesophageal hernias.

Gasless laparoscopic surgery plus abdominal wall lifting for giant hiatal hernia-our single-center experience

Giant hiatal hernia (GHH) comprises 5% of hiatal hernia and is associated with significant complications. The traditional operative procedure, no matter transthoracic or transabdomen repair of giant hiatal hernia, is characteristic of more invasion and more complications. Although laparoscopic repair as a minimally invasive surgery is accepted, a part of patients can not tolerate pneumoperitoneum because of combination with cardiopulmonary diseases or severe posterior mediastinal and neck emphesema during operation. The aim of this article was to analyze our experience in gasless laparoscopic repair with abdominal wall lifting to treat the giant hiatal hernia. We performed a retrospective review of patients undergoing gasless laparoscopic repair of GHH with abdominal wall lifting from 2012 to 2015 at our institution. The GHH was defined as greater than one-third of the stomach in the chest. Gasless laparoscopic repair of GHH with abdominal wall lifting was attempted in 27 patients. Mean age was 67 years. The results showed that there were no conversions to open surgery and no intraoperative deaths. The mean duration of operation was 100 min (range: 90-130 min). One-side pleura was injured in 4 cases (14.8%). The mean postoperative length of stay was 4 days (range: 3-7 days). Median follow- up was 26 months (range: 6-38 months). Transient dysphagia for solid food occurred in three patients (11.1%), and this symptom disappeared within three months. There was one patient with recurrent hiatal hernia who was reoperated on. Two patients still complained of heartburn three months after surgery. Neither reoperation nor endoscopic treatment due to signs of postoperative esophageal stenosis was required in any patient. Totally, satisfactory outcome was reported in 88.9% patients. It was concluded that the gasless laparoscopic approach with abdominal wall lifting to the repair of GHH is feasible, safe, and effective for the patients who cannot tolerate the pneumoperitoneum.

Laparoscopic hernioplasty of hiatal hernia

Laparoscopic surgery is a good choice for surgical treatment of hiatal hernia because of its mini-invasive nature and intraperitoneal view and operating angle. This article will talk about the surgical procedures, technical details, precautions and complications about laparoscopic hernioplasty of hiatal hernia.

Surgical Treatment of Paraesophageal Hernias: A Review

The management of paraesophageal hernia (PEH) can be challenging due to the lack of consensus regarding indications and principles of operative treatment. In addition, data about the pathophysiology of the hernias are scant. Therefore, the goal of this review is to shed light and describe the classification, pathophysiology, clinical presentation, and indications for treatment of PEHs, and provide an overview of the surgical management and a description of the technical principles of the repair.

The laparoscopic hiatoplasty with antireflux surgery is a safe and effective procedure to repair giant hiatal hernia

Background

Although minimally invasive repair of giant hiatal hernias is a very surgical challenge which requires advanced laparoscopic learning curve, several reports showed that is a safe and effective procedure, with lower morbidity than open approach. In the present study we show the outcomes of 13 patients who underwent a laparoscopic repair of giant hiatal hernia.

Methods

A total of 13 patients underwent laparoscopic posterior hiatoplasty and Nissen fundoplication. Follow-up evaluation was done clinically at intervals of 3, 6 and 12 months after surgery using the Gastro-oesophageal Reflux Health-Related Quality of Life scale, a barium swallow study, an upper gastrointestinal endoscopy, an oesophageal manometry, a combined ambulatory 24-h multichannel impedance pH and bilirubin monitoring. Anatomic recurrence was defined as any evidence of gastric herniation above the diaphragmatic edge.

Results

There were no intraoperative complications and no conversions to open technique. Symptomatic GORD-HQL outcomes demonstrated a statistical significant decrease of mean value equal to 3.2 compare to 37.4 of preoperative assessment (p < 0.0001). Combined 24-h multichannel impedance pH and bilirubin monitoring after 12 months did not show any evidence of pathological acid or non acid reflux.

Conclusion

All patients were satisfied of procedure and no hernia recurrence was recorded in the study group, treated respecting several crucial surgical principles, e.g., complete sac excision, appropriate crural closure, also with direct hiatal defect where possible, and routine use of antireflux procedure.

Laparoscopic management of totally intra-thoracic stomach with chronic volvulus

AIM: To evaluate the outcomes of patients who underwent laparoscopic repair of intra-thoracic gastric volvulus (IGV) and to assess the preoperative work-up.

METHODS: A retrospective review of a prospectively collected database of patient medical records identified 14 patients who underwent a laparoscopic repair of IGV. The procedure included reduction of the stomach into the abdomen, total sac excision, reinforced hiatoplasty with mesh and construction of a partial fundoplication. All perioperative data, operative details and complications were recorded. All patients had at least 6 mo of follow-up.

RESULTS: There were 4 male and 10 female patients. The mean age and the mean body mass index were 66 years and 28.7 kg/m², respectively. All patients presented with epigastric discomfort and early satiety. There was no mortality, and none of the cases were converted to an open procedure. The mean operative time was 235 min, and the mean length of hospitalization was 2 d. There were no intraoperative complications. Four minor complications occurred in 3 patients including pleural effusion, subcutaneous emphysema, dysphagia and delayed gastric emptying. All minor complications resolved spontaneously without any intervention. During the mean follow-up of 29 mo, one patient had a radiological wrap herniation without volvulus. She remains symptom free with daily medication.

CONCLUSION: The laparoscopic management of IGV is a safe but technically demanding procedure. The best outcomes can be achieved in centers with extensive experience in minimally invasive esophageal surgery.

Redo laparoscopic repair of benign esophageal disease

Laparoscopic fundoplication for gastroesophageal reflux disease has been associated with excellent symptom control. Compared with medical treatment, laparoscopic Nissen fundoplication has shown favorable control of typical reflux symptoms. However, in approximately 2% to 17% of patients, surgical treatment fails. The role of reoperative repair for reflux disease and the factors that contribute to it are examined.

Laparoscopic Repair of Giant Paraesophageal Hernia with Synthetic Mesh: 45 Consecutive Cases

Giant paraesophageal hernias (PEHs) are associated with progression of symptoms in up to 45 per cent of patients. Recently, many series have reported that laparoscopic repair of PEH is technically feasible, effective, and safe. A retrospective review of the University of Athens tertiary care hospitals patient database and the patient medical records identified 45 patients who underwent elective repair of a giant PEH between 2002 and 2009. Elective laparoscopic repair of a giant PEH was attempted in 45 patients who were treated with Gore-Tex dual mesh with or without Nissen fundoplication. They all had a mesh repair. Intraoperative complications included one pulmonary embolism and one recurrent hernia. The use of a mesh seems to be effective in the treatment of large hernias. It appears to offer the benefit of a shorter hospital stay and a quicker recovery.

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.

DISCUSSION

A thorough understanding of the tenets of the operation and advanced skills in minimally invasive laparoscopy are needed for long-term freedom from symptomatic and anatomic recurrence. These include complete reduction of the hernia sac from the mediastinum back into the abdomen with careful preservation of the integrity of muscle and peritoneal lining of the crura, aggressive and complete mobilization of the esophagus to the level of the inferior pulmonary vein, vagal preservation, clear identification of the gastroesophageal junction to allow accurate assessment of the intraabdominal esophageal length, and use of Collis gastroplasty when esophageal lengthening is required for a tension-free intraabdominal repair. Liberal mobilization of the phrenosplenic and phrenogastric attachments substantially increases the mobility of the left limb of the crura, allowing for a tension-free primary closure in a large percentage of patients.

CONCLUSION

The following describes our current approach to laparoscopic paraesophageal hernia repair following a decade of refinement in a high-volume center.

Hiatal hernias

Esophageal hiatal hernias have been reported to affect anywhere from 10 to 50% of the population. Hiatal hernias are characterized by a protrusion of the stomach into the thoracic cavity through a widening of the right crus of the diaphragm. There are four types of esophageal hiatal hernias: sliding (type I), paraesophageal (type II), and combined (type III), which include elements of types I and II, and giant paraesophageal (type IV). Each type may present with different symptoms and complications. The potential severity of symptoms necessitates proper and prompt diagnosis. Diagnosis is established with the use of barium swallow on chest radiographs. Treatment for sliding hernias involves laparoscopic fundoplication. The aim of our paper is to review the extensive literature regarding hiatal hernias in an effort to enhance awareness and diagnosis of this pathology.

Laparoscopic repair of paraesophageal hernia. Long-term follow-up reveals good clinical outcome despite high radiological recurrence rate

OBJECTIVE

The purpose of this report is to evaluate and compare the long-term objective and subjective outcome after laparoscopic paraesophageal hernia repair (LPHR).

BACKGROUND

Short-term symptomatic results of LPHR are often excellent. However, a high recurrence rate is detected at objective radiographic follow-up.

METHODS

Retrospective review of a prospectively gathered database of consecutive patients undergoing LPHR with and without reinforced crural repair at a single institution. Subjective and objective outcomes were assessed by using a structured symptoms questionnaire, Gastrointestinal Quality-of-Life Index, satisfaction score, and barium esophagogram.

RESULTS

From September 1991 to September 2005, LPHR was performed in 85 patients (median age, 66 years) with (25 patients) and without (60 patients) reinforced crural repair. Two patients (3%) underwent laparoscopic reoperation, for severe dysphagia and for symptomatic recurrence, respectively. Subjective outcome, available for 64 patients (75%), improved significantly at median follow-up of 118 months with a postoperative median Gastrointestinal Quality-of-Life Index score of 116. Radiographic recurrence (median follow-up, 99 months) occurred in 23 (66%) of the 35 patients, independently of age at operation, type of paresophageal hiatal hernias, and crural reinforcement, and showed no impact on quality of life.

CONCLUSIONS

Although providing excellent symptomatic results, long-term objective evaluation of LPHR reveals a high recurrence rate even with reinforced cruroplasty. A tailored, lengthening gastroplasty and reinforced cruroplasty based on objective intraoperative evaluation, and not only on surgeon's personal judgment, may be the answer to recurrences.

Laparoscopic anterior hemifundoplication and hiatoplasty for the treatment of upside-down stomach: mid- and long-term results after 40 patients

BACKGROUND

Treatment of type 4 hiatal hernia using a minimally invasive approach is challenging and requires good familiarity with this technique.

METHODS

From October 1992 to August 2010, 40 patients with a median age of 68 years underwent laparoscopic anterior hemifundoplication surgery for upside-down stomach and were included in our prospective study. The median symptoms duration was 5 years. The leading clinical symptoms were postprandial, epigastric, or retrosternal pain (80%), heartburn (78%), regurgitation (80%), dysphagia (53%), and anemia (48%). Preoperative evaluation included blood test, chest X-ray, upper endoscopy, and barium swallow. In some patients an esophageal 24-h pH study and esophageal manometry were performed. The median follow-up was 46 months using a standardized questionnaire, including Smiley score, modified Visick score, gastrointestinal quality-of-life index (GQLI), and specific reflux symptoms score.

RESULTS

Surgery was finished laparoscopically in 39 patients (97%). One patient had to be converted to an open procedure because of severe adhesions. Mesh hiatoplasty had to be performed in one patient due to a large hiatal defect. Median operative time was 160 min (range=90-275) and median blood loss was 5 ml (range=0-300). Seven patients (18%) presented with acute symptoms. Intraoperative technical complications occurred in four patients (10%) and nontechnical complications in two cases (5%). Median postoperative hospital stay was 5 days (range=2-17). Postoperative complications occurred in two patients (5%): one pleural effusion and one surgical emphysema. There was no mortality or symptomatic recurrence. All scores showed significant improvement and patient satisfaction.

CONCLUSION

Laparoscopic treatment of type 4 hiatal hernia is safe. With respect to the quality of life, anterior hemifundoplication is highly effective.

Paraoesophageal herniation: a review

BACKGROUND

Paraoesophageal hiatus herniae repair can represent a formidable challenge. Afflicted patients tend to be elderly with multiple infirmities often with cardio-pulmonary dysfunction. They may present acutely with protracted vomiting and concurrent biochemical imbalances and it is a technically demanding procedure. There are several debated issues regarding operative technique. This paper will attempt to explain the nature of paraoesophageal hiatus herniae and reviews the recommended pre-operative investigations and operative strategies available.

METHODS

A literature search was performed from Pubmed and suitable clinical papers were selected for review. When attempting to address whether meshes should be included routinely, electronic searches were performed in PubMed, Embase and the Cochrane library. A systematic search was done with the following medical subject heading (MeSH) terms: 'paraoesophageal hernia repair' AND 'mesh'. In PubMed and Embase the search was carried out with the limits 'humans', 'English language', 'all adult: 19+ years' and 'published between 1990 and 2010'. A manual cross-reference search of the bibliographies of included papers was carried out to identify additional potentially relevant studies.

RESULTS

Firm conclusions are difficult to draw due to the diverse nature of both the disorder and the presentation however principals of management can be suggested. Similarly, there is no conclusive proof of the most effective operative technique and therefore the options are described.

CONCLUSION

Due to the relative lack of cases encountered at smaller institutions, there is a good argument for centralisation of these cases into regional centres to allow research and facilitate improvements in care.

Laparoscopic repair of large hiatal hernia without prosthetic reinforcement: late results and relevance of anterior gastropexy

BACKGROUND

Laparoscopic treatment of large hiatal hernias seems to be associated with a high recurrence rate that some authors suggest to bring down by performing prosthetic closure of the hiatus. However, prosthetic repair remains controversial owing to severe and still underestimated complications. The aims of this study were to assess the long-term functional and objective results of laparoscopic treatment without prosthetic patch, and to identify the risk factors of recurrence.

METHODS

From November 1992 to March 2009, 89 patients underwent laparoscopic treatment of a large hiatal hernia without prosthetic patch, involving excision of the hernial sac, cruroplasty, fundoplication, and often anterior gastropexy. The postoperative assessment consisted of a barium esophagram on day 2, an office visit at 2 months with a 24-h pH study, an esophageal manometry, and then a long-term prospective yearly follow-up with a barium esophagram at 2 years.

RESULTS

Out of the 89 laparoscopic procedures, four required a conversion (4.4%). Seventy-seven patients underwent a Boerema's anterior gastropexy (86.5%). The morbidity rate was 7.8%, and the mortality rate was nil. Eleven patients (12.3%) were lost to follow-up. We had 91.5% of very good early functional results and 75.3% of good results after a mean follow-up of 57.5 months. Fourteen recurrences of hiatal hernias (15.7%) were identified, four of which (28.6%) occurred early after surgery. Three factors seemed significantly associated with recurrence: the absence of anterior gastropexy (p = 0.0028), the group of younger patients (p = 0.03), and a history of abdominal surgery (p = 0.01).

CONCLUSION

Large hiatal hernias can be treated by laparoscopy without prosthetic patch with a satisfying long-term result. Performing anterior gastropexy seems to significantly reduce the recurrences.

Giant hiatal hernia

A giant hiatal hernia (HH) is a hernia that includes at least 30% of the stomach in the chest, although a uniform definition does not exist; most commonly, a giant HH is a type III hernia with a sliding and paraesophageal component. The etiology of giant HH is not entirely clear, and two potential mechanisms exist: (1) gastroesophageal reflux disease (GERD) leads to esophageal scarring and shortening with resulting traction on the gastroesophageal junction and gastric herniation; and (2) chronic positive pressure on the diaphragmatic hiatus combined with a propensity to herniation leads to gastric displacement into the chest, resulting in GERD. The short esophagus and GERD are key concepts to understanding the pathophysiology of giant HH, and these concepts are critical to address this problem appropriately. A successful repair of giant HH requires adherence to basic hernia repair principles (ie, hernia sac excision, tension-free repair), recognition and correction of a short esophagus, and a well-performed antireflux procedure. Recurrence rates for open giant HH repairs in expert hands range between 2% and 12%; large series have demonstrated that meticulous laparoscopic surgical technique can emulate the results of open giant HH repair.

Paraesophageal hernia: clinical presentation, evaluation, and management controversies

Practically, hiatal hernias are divided into sliding hiatal hernias (type I) and PEH (types II, III, or IV). Patients with PEH are usually symptomatic with GERD or obstructive symptoms, such as dysphagia. Rarely, patients present with acute symptoms of hernia incarceration, such as severe epigastric pain and retching. A thorough evaluation includes a complete history and physical examination, chest radiograph, UGI series, esophagogastroscopy, and manometry. These investigations define the patient's anatomy, rule out other disease processes, and confirm the diagnosis. Operable symptomatic patients with PEH should be repaired. The underlying surgical principles for successful repair include reduction of hernia contents, removal of the hernia sac, closure of the hiatal defect, and an antireflux procedure. Debate remains whether a transthoracic, transabdominal, or laparoscopic approach is best with good surgical outcomes being reported with all three techniques. Placement of mesh to buttress the hiatal closure is reported to reduce hernia recurrence. Long-term follow-up is required to determine whether the laparoscopic approach with mesh hiatoplasty becomes the procedure of choice.

Should elective repair of intrathoracic stomach be encouraged?

BACKGROUND

Given our aging population, patients with an intrathoracic stomach are an increasing clinical problem. The timing of repair remains controversial, and most reports do not delineate morbidity of emergent presentation. The aim of the study was to compare the morbidity and mortality of elective and emergent repair.

METHODS

Study population consisted of 127 patients retrospectively reviewed undergoing repair of intrathoracic stomach from 2000 to 2006. Repair was elective in 104 and emergent in 23 patients. Outcome measures included postoperative morbidity and mortality.

RESULTS

Patients presenting acutely were older (79 vs. 65 years, p < 0.0001) and had higher prevalence of at least one cardiopulmonary comorbidity (57% vs. 21%, p = 0.0014). They suffered greater mortality (22% vs. 1%, p = 0.0007), major (30% vs. 3%, p = 0.0003), and minor (43% vs. 19%, p = 0.0269) complications compared to elective repair. On multivariate analysis, emergent repair was a predictor of in-hospital mortality, major complications, readmission to intensive care unit, return to operating room, and length of stay.

CONCLUSION

Emergent surgical repair of intrathoracic stomach was associated with markedly higher mortality and morbidity than elective repair. Although patients undergoing urgent surgery were older and had more comorbidities than those having an elective procedure, these data suggest that elective repair should be considered in patients with suitable surgical risk.

Outcomes after a decade of laparoscopic giant paraesophageal hernia repair

OBJECTIVE

Laparoscopic repair of giant paraesophageal hernia is a complex operation requiring significant laparoscopic expertise. Our objective was to compare our current approach and outcomes for laparoscopic repair of giant paraesophageal hernia with our previous experience.

METHODS

A retrospective review of patients undergoing nonemergency laparoscopic repair of giant paraesophageal hernia, stratified by early versus current era (January 1997-June 2003 and July 2003-June 2008), was performed. We evaluated clinical outcomes, barium esophagogram, and quality of life.

RESULTS

Laparoscopic repair of giant paraesophageal hernia was performed in 662 patients (median age 70 years, range 19-92 years) with a median percentage of herniated stomach of 70% (range 30%-100%). With time, use of Collis gastroplasty decreased (86% to 53%), as did crural mesh reinforcement (17% to 12%). Current era patients were 50% more likely to have a Charlson comorbidity index score greater than 3. Thirty-day mortality was 1.7% (11/662). Mortality and complication rates were stable with time, despite increasing comorbid disease in current era. Postoperative gastroesophageal reflux disease health-related quality of life scores were available for 489 patients (30-month median follow-up), with good to excellent results in 90% (438/489). Radiographic recurrence (15.7%) was not associated with symptom recurrence. Reoperation occurred in 3.2% (21/662).

CONCLUSIONS

With time, we have obtained significant minimally invasive experience and refined our approach to laparoscopic repair of giant paraesophageal hernia. Perioperative morbidity and mortality remain low, despite increased comorbid disease in the current era. Laparoscopic repair provided excellent patient satisfaction and symptom improvement, even with small radiographic recurrences. Reoperation rates were comparable to the best open series.

Hiatal hernia recurrence: surgical complication or disease? Electron microscope findings of the diaphragmatic pillars

INTRODUCTION

Although laparoscopic Nissen fundoplication has been recognized as the standard of care for hiatal hernia (HH) repair, HH recurrence due to breakdown of the hiatoplasty have been reported as a common mechanism of failure after primary repair. Different surgical techniques for diaphragmatic pillars closure have been proposed, but the problem remains unsolved. The authors hypothesized that ultrastructural illness may be implicated in this recurrence. The aim of this study was to investigate the presence of changes at esophageal hiatal area in patients with and without HH.

MATERIALS AND METHODS

One hundred and thirty-two laparoscopic samples from phrenoesophageal membrane and diaphragmatic crura were collected from 33 patients with gastroesophageal reflux disease and HH (HH group) and 60 samples from 15 patients without HH enrolled as the control group (NHH group). All specimens were processed and analyzed by transmission electron microscopy.

RESULTS

Muscular and connective samples from the NHH group showed no ultrastructural alterations; similar results were found in phrenoesophageal ligament samples from the HH group. In contrast, 94% of the muscular samples obtained from the crura of the HH group have documented four main types of alterations. In 75% of HH patients, the pillar lesions were severe.

CONCLUSION

Patients with hiatal hernia have ultrastructural abnormalities at the muscular tissue of the crura that are not present in patients with a normal gastroesophageal junction. There is no difference in the microscopic damage at the connective tissue of the phrenoesophageal membrane surrounding the esophagus of the two groups of patients. The outcome of antireflux surgery could depend not only on the adopted surgical technique but also on the underlying status of the diaphragmatic crura.

Current controversies in paraesophageal hernia repair

The management of paraesophageal hernia (PEH) has become one of the most widely debated and controversial areas in surgery. PEHs are relatively uncommon, often presenting in patients entering their seventh or eighth decades of life. Patients who have PEH often bear complicating medical comorbidities making them potentially poor operative candidates. Taking this into account makes surgical management of these patients all the more complex. Many considerations must be taken into account in formulating a management strategy for patients who have PEHs, and these considerations have led surgeons into ongoing debates in recent decades.

Laparoscopic repair of giant paraesophageal hernia results in long-term patient satisfaction and a durable repair

BACKGROUND

Laparoscopic repair of giant paraesophageal hernia (LRGPEH) is routinely performed in many centers, but high recurrence rates have led to concerns regarding this approach. We evaluate long-term recurrence rates, symptom improvement and correlation with radiographic recurrence, and risk factors for recurrence in our cohort of patients.

METHODS

A cohort of consecutive patients with a minimum of 5 years potential follow-up (1997-2003) post-LRGPEH was identified from a prospective database. Clinical outcomes, barium esophagram (BE), and quality-of-life (QoL) measures were obtained.

RESULTS

Laparoscopic repair was successful in 185/187 patients. Routine clinical follow-up (median 77 months) was available for all patients. Detailed questionnaires and BE were obtained in 65% and 82% of patients. Gastroesophageal Reflux Disease Health-Related QoL (GERD-HRQoL) scores were excellent to good in 86.7%. BE (median 51 months) demonstrated radiographic hernia recurrence in 15% of patients, but without consistent symptom association. There was a trend toward increased risk of radiographic recurrence in patients with a history of pulmonary disease (p = 0.08). Seven reoperations (4.4%) were performed for symptomatic recurrence (median 44 months postoperative).

CONCLUSIONS

LRGPEH performed in our minimally invasive center of excellence resulted in a durable repair with a high degree of satisfaction and preservation of GERD-related QoL at a median follow-up of over 6 years.

Primary laparoscopic and open repair of paraesophageal hernias: a comparison of short-term outcomes

The choice of the optimal surgical approach for repairing paraesophaeal hernias (PEH) is debated. Our objective is to evaluate the short-term outcomes of primary laparoscopic and open repairs of PEH performed in the Calgary Health Region. A retrospective review of all patients undergoing repair of PEH between October 1999 and February 2005 was performed. The outcome measures evaluated included intra-operative parameters and post-operative variables, mortality rates, recurrence rates and patient satisfaction. A total of 93 patients underwent either a laparoscopic (n = 46) or open (n = 47) primary PEH repair. The laparoscopic approach was associated with a longer mean operative time (3.1 +/- 1.2 hours vs. 2.5 +/- 0.7 hours, P = 0.005) but resulted in a shorter overall hospital stay (5 days [2-16 days]vs. 10 days [5-24 days]; P < 0.001), and fewer post-operative complications (10/46 [22%]vs. 25/47 [53%]P = 0.002). Although the follow-up was short (laparoscopic 16 months; open 18 months), a 9% recurrence rate was reported with both approaches. Patient satisfaction using the Gastroesophageal Disease Health-Related Quality Of Life questionnaire was similar in both groups (P = 0.861) with most patients reporting excellent outcomes (laparoscopic: 32/36 [89%]; open 27/35 [77%]). Our review suggests that the laparoscopic approach is safe with shorter hospital stay and recovery. Although early follow-up suggests that recurrence rates and patient satisfaction are similar, long-term follow-up is required to determine whether the laparoscopic approach will become the procedure of choice.

Prosthetic mesh repair of large and recurrent diaphragmatic hernias

BACKGROUND

Laparoscopic repair of large paraesophageal hernias (PEH) is associated with significant recurrence rates. Use of prosthetic mesh to complete tension-free repair of the hiatus has been suggested to decrease the recurrence rate.

METHODS

Fifty-nine patients with large (n = 44) or recurrent (n = 15) PEH were operated on via the laparoscopic approach with the use of prosthetic mesh. Patients were followed with office visits and phone interviews. All patients were referred for barium studies. Data analysis included all patients, including conversions, on an intention-to-treat basis.

RESULTS

Followup was completed in 56 (95%) patients. Mean followup time was 28.4 months. Forty patients (74%) had significant relief of all symptoms. Barium studies were performed in 45 patients (80.3%), including all symptomatic patients. Fifteen patients (33%) had a small sliding hernia, six (13.3%) had recurrent PEH, and four (8.8%) had narrowing of the gastroesophageal junction. Most patients with small hiatal hernias were symptomatic (60%). All responded to medical treatment.

CONCLUSIONS

Laparoscopic repair of large PEH with reinforcement mesh is feasible and safe with excellent short-term results. Long-term followup shows a low PEH recurrence requiring reoperation, but a significant number of patients develop symptomatic recurrent small hiatal hernias that can be managed nonoperatively.

Wedge gastroplasty and reinforced crural repair: Important components of laparoscopic giant or recurrent hiatal hernia repair

OBJECTIVE

Laparoscopic repair of a giant hiatal hernia (>50% of the stomach above the diaphragm) is associated with short-term recurrence rates of 12% to 42%. Recurrent hiatal hernias often have significantly altered anatomy, making laparoscopic repair challenging. We hypothesized that increasing intra-abdominal esophageal length by means of Collis wedge gastroplasty, complete fat-pad dissection, hernia-sac excision, and primary reinforced crural repair would minimize short-term recurrence and provide adequate symptomatic relief.

METHODS

From January 1, 2001, though May 1, 2005, 61 patients underwent laparoscopic repair of a giant or recurrent hiatal hernia with a Collis wedge gastroplasty and Nissen fundoplication. Symptomatic outcomes were assessed with a validated questionnaire (Gastroesophageal Reflux Disease Health-Related Quality of Life). We obtained postoperative radiographic imaging to objectively assess anatomic results at a median of 1.13 years.

RESULTS

Of the 61 patients, 12 (20%) were referred to our institution after previous repairs. Operating time averaged 308 +/- 103 minutes. The median hospital stay was 4 days. Postoperative complications occurred in 5 (8.2%) patients. One (1.6%) patient died of cardiac complications. Postoperatively, 52 (85%) patients completed the questionnaire with mean a Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaire score of 1.15 +/- 2.78 (scale, 0-45; 0 = asymptomatic). Overall, 51 (98%) of the 52 respondents were satisfied with their surgical outcome. Postoperative radiographic data were available for 54 (89%) patients. We identified no recurrences at 1-month follow-up, and only 4.7% (2/42) had evidence of radiographic recurrence at 1 year or more.

CONCLUSIONS

Consistent use of a Collis wedge gastroplasty with reinforced crural repair minimizes short-term recurrence after minimally invasive giant hiatal hernia repair. Symptomatic results are excellent in most patients.

Controversies in paraesophageal hernia repair; a review of literature

BACKGROUND

The surgical repair of paraesophageal hiatal hernias (PHH) can be performed by endoscopic means, but the procedure is not standardized and results have not been evaluated systematically so far. The aim of this review article was to clarify controversial subjects on the surgical approach and technique, i.e., recurrence rate after conventional versus laparoscopic PHH treatment, results of mesh reinforcement of the cruroplasty, the necessity for additional antireflux surgery, and indications for an esophageal lengthening procedure.

METHODS

An electronic Medline search was performed to identify all publications reporting on laparoscopic and conventional PHH surgery. The computer search was followed by additional hand searches in books, journals, and related articles. All types of publications were evaluated because of a lack of high-level evidence studies such as randomized controlled trials. Critical analysis followed for all articles describing a study population of >10 patients and those reporting postoperative outcome.

RESULTS

A total of 32 publications were reviewed. Randomized controlled trials comparing laparoscopic and open techniques could not be identified. Nineteen of the publications described the results of retrospective series. Therefore, most of the studies retrieved were low in hierarchy of evidence (level II-c or lower). The overall median hospital time as published was 3 days for patients operated laparoscopically and 10 days in the conventional group. Postoperative complications, such as pneumonia, thrombosis, hemorrhage, and urinary and wound tract infections, appeared to be more frequent after conventional surgery. Follow-up was longer for conventional surgery (median 45 months versus 17.5 months after the laparoscopic technique). Recurrence rates reported were higher in patients operated conventionally (median 9.1% versus 7.0% for patients operated laparoscopically). Recurrences after PHH repair may decrease with usage of mesh in the hiatus, although uniform criteria for this procedure are lacking. No conclusions could be drawn regarding the necessity for an additional antireflux procedure. Furthermore, uniform specific indications for the need of an esophageal lengthening procedure or preoperative assessment methods for shortened esophagus could not be detected.

CONCLUSION

Treatment based on standardized protocols for preoperative assessment and postoperative follow-up is required to clarify the current controversies.

Laparoscopic repair of paraesophageal hernia

Laparoscopic repair of paraesophageal hernias is rapidly replacing the traditional open approach. Regardless of the approach, certain aspects of repairing paraesophageal hernias have proven to be beneficial and others remain controversial. This article addresses the effectiveness of the laparoscopic approach, the accepted and controversial technical aspects of repair, and which patients should undergo surgical correction of the hernia.

A 25-year experience with open primary transthoracic repair of paraesophageal hiatal hernia

OBJECTIVE

The optimal surgical treatment of paraesophageal hiatal hernia is in debate. Our experience with a traditional transthoracic approach was reviewed to provide "benchmark" data against which newer surgical techniques can be measured.

METHODS

Between 1977 and 2001, 240 patients had primary transthoracic repair of paraesophageal hiatal hernia. Presenting complaints included reflux (69%), pain (67%), dysphagia (36%), and bleeding or anemia (33%). Preoperative esophageal function testing showed abnormal reflux in 86%. Hernia types were combined (type III) in 92% and type IV in 8%. All patients had reduction of the hernia and a concomitant antireflux procedure. An esophageal lengthening Collis gastroplasty was performed in 96%.

RESULTS

There were 3 perioperative deaths (1.7%). The median length of hospital stay was 7 days. Early complications requiring reoperation occurred in 12 patients (5%) and included recurrent hernia in 4, leak in 3, and a tight hiatal closure in 3. Mean follow-up in 226 patients was 42 months (median 27.8 months). Satisfactory results were obtained in 86% of patients. Follow-up complaints (moderate or persistent symptoms) included dysphagia (4), reflux (1), dumping (3), and post-thoracotomy pain (1). Routine postoperative barium radiographs showed intact repair in 71% (108/153). Of 19 patients with an anatomic recurrence, 4 (2%) had more than a partial asymptomatic migration of the fundoplication and required reoperation. Postoperative esophageal function testing, obtained in 28% of the patients, showed abnormal gastroesophageal reflux in 2.

CONCLUSION

Open transthoracic repair of paraesophageal hiatal hernia provides good to excellent long-term control of both the hernia and gastroesophageal reflux with relatively low early morbidity.

Short esophagus: literature incidence

There are controversies regarding existence and incidence of short esophagus. The authors reviewed the literature incidence of short esophagus among operated patients due to gastroesophageal reflux disease in the last 3 years. The overall incidence of short esophagus was 1.53%. The proposed risk factors (paraesophageal hernia, Barrett's esophagus, reoperation, esophageal strictures and access route) do have a higher incidence of short esophagus, with the exception of the Barrett's esophagus. Although several biases can be associated with the review, the authors identified the short esophagus incidence in the literature.

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

Laparoscopic paraesophageal hernia repairs performed in 116 patients between 1992 and 2001 were prospectively analyzed. Perioperative outcomes were assessed and follow-up was performed under protocol. There were 85 female and 31 male patients who had a mean (+/- SD) age of 65 +/- 13 years and an American Society of Anesthesiology score of 2.3 +/- 0.6. All but two patients underwent an antireflux procedure. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in six patients, and prosthetic closure of the hiatus in six patients. Major complications occurred in five patients (4.3%) with two postoperative deaths (1.7%). Mean follow-up was 30 +/- 25 months; 96 patients (83%) have been followed for more than 6 months. Among these patients, 73 (76%) are asymptomatic, 11 (11%) have mild symptoms, and 12 (13%) take antacid medications. Protocol barium esophagograms were obtained in 69% of patients at 6 to 12 months' follow-up. Recurrence of hiatal hernia was documented in 21 patients (22% overall and in 32% of those undergoing contrast studies). Reoperation has been performed in three patients (3%). When only the patients with recurrent hiatal hernias are considered, 13 (62%) are symptomatic but only six (28%) require medication for symptoms. Laparoscopic paraesophageal hernia repair is generally safe, even in this high-risk group. This study confirms a relatively high incidence of recurrent hiatal abnormalities after paraesophageal hernia repair; however, most recurrent hiatal hernias are small and only 3% have required reoperation. Protocol esophagograms detect recurrences that are minimally symptomatic. Improved techniques must be devised to improve the long-term outcomes of laparoscopic paraesophageal hernia repair.

Results of laparoscopic repair of giant paraesophageal hernias: 200 consecutive patients

BACKGROUND

Giant paraesophageal hernias (GPEH) have traditionally required open operations. Increasingly, a laparoscopic approach is being applied to more complex esophageal surgery. Our objective was to update our growing experience with laparoscopic repair of GPEH.

METHODS

We performed a retrospective review at our institution of patients undergoing laparoscopic repair of GPEH from July 1995 to July 2001. The GPEH was defined as greater than one-third of the stomach in the chest.

RESULTS

Elective laparoscopic repair of a GPEH was attempted in 203 patients. Mean age was 67 years. The most common symptoms included heartburn (96 patients), dysphagia (72), epigastric pain (56), and vomiting (47 patients). Laparoscopic procedures included 69 Nissens, 112 Collis-Nissens, and 19 other procedures. There were three open conversions due to adhesions, but no intraoperative emergencies. Median length of stay was 3 days (range, 1 to 120 days). Minor or major complications occurred in 57 patients (28%). There were six postoperative esophageal leaks (3%), and 1 death. Median follow-up was 18 months. Five patients required reoperation for recurrent hiatal hernia. Excellent results were reported in 128 (84%) patients, 12 (8%) had a good result, 7 (5%) fair, and 5 (3%) poor (based on postoperative follow-up and GERD questionnaire). The mean postoperative GERD Health-related Quality of Life Score was 2.4 (scale 0 to 45; 0 = no symptoms, 45 = worst).

CONCLUSIONS

Laparoscopic repair of GPEH is possible in the majority of patients with acceptable morbidity, a median length of hospital stay of 3 days and excellent intermediate-term results in an experienced center.

Paraesophageal Hernia

The definitive management of paraesophageal hernia is surgical repair. The current standard of care is the laparoscopic paraesophageal hernia repair in patients who are medically fit for general anesthesia and operation. When patients are considered for operative repair, they should undergo diagnostic testing, including upper endoscopy, upper gastrointestinal series, and esophageal manometry.

Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases

OBJECTIVE

To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH).

SUMMARY BACKGROUND DATA

Laparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery.

METHODS

From July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores.

RESULTS

There were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50).

CONCLUSION

This report represents the largest series to date of laparoscopic repair of giant PEH. In the authors' center with extensive experience in minimally invasive surgery, laparoscopic repair of giant PEH was successfully performed in 97% of patients, with a minimal complication rate, a 2-day length of stay, and good intermediate results.