Paraoesophageal hernia repair with and without concomitant fundoplication

Hernia emergencies

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.

Laparoscopic mesh-augmented hiatoplasty without fundoplication as a method to treat large hiatal hernias

Purpose

Laparoscopic hiatal hernia repair with additional fundoplication is a commonly recommended standard surgical treatment for symptomatic large hiatal hernias with paraesophageal involvement (PEH). However, due to the risk of persistent side effects, this method remains controversial. Laparoscopic mesh-augmented hiatoplasty without fundoplication (LMAH), which combines hiatal repair and mesh reinforcement, might therefore be an alternative.

Methods

In this retrospective study of 55 (25 male, 30 female) consecutive PEH patients, the perioperative course and symptomatic outcomes were analyzed after a mean follow-up of 72 months.

Results

The mean DeMeester symptom score decreased from 5.1 to 1.8 (P < 0.001) and the gas bloating value decreased from 1.2 to 0.5 (P = 0.001). The dysphagia value was 0.7 before surgery and 0.6 (P = 0.379) after surgery. The majority of the patients were able to belch and vomit (96 and 92 %, respectively). Acid-suppressive therapy on a regular basis was discontinued in 68 % of patients. In 4 % of patients, reoperation was necessary due to recurrent or persistent reflux. A mesh-related stenosis that required endoscopic dilatation occurred in 2 % of patients.

Conclusions

LMAH is feasible, safe and provides an anti-reflux effect, even without fundoplication. As operation-related side effects seem to be rare, LMAH is a potential treatment option for large hiatal hernias with paraesophageal involvement.

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.

Management of acute paraesophageal hernia

BACKGROUND

Acute paraesophageal hernia is a surgical emergency presenting with sudden chest or abdominal pain, dysphagia, vomiting, retching or significant anemia. Severe cases can present with respiratory failure or systemic sepsis. This can be due to gastric volvulus, incarceration, strangulation, severe bleeding or perforation. Traditionally this has been treated with an open surgery. The purpose of this study is to develop a management algorithm and evaluate the role of a laparoscopic approach for these cases.

METHODS

A retrospective chart review was performed for patients operated on for paraesophageal hernia at the Peter Lougheed Centre from 2004 to 2007 inclusive. Patients admitted with acute symptoms requiring emergency surgery were selected for the study.

RESULTS

Twenty patients were identified. Seventeen patients underwent successful laparoscopic repair including reduction of the hernia content, excision of the sac, crural closure, and fundoplication (Dor or Nissen). Fifteen of these were done semi-urgently. Three patients had open repair. One patient was converted to open due to ischemic gastric perforation and peritoneal contamination. Another patient had right thoracotomy followed by laparotomy for mediastinal contamination. A third patient with a body mass index (BMI) of 49 kg/m(2) was converted to open for a type VI paraesophageal hernia. Mean operating time for the laparoscopic group was 190.5 min, blood loss was minimal, and mean postoperative hospital stay was 8.2 days. There were no significant perioperative complications. All patients were tolerating regular diet on short-term follow-up.

CONCLUSION

Laparoscopic repair of acute paraesophageal hernia is safe and feasible with low morbidity and mortality. It affords all the benefits of minimally invasive surgery in a group of patients that are often elderly and suffer from multiple medical problems. Based on our experience, we advocate the laparoscopic technique to repair acute paraesophageal hernias in patients with no obvious perforation. A management algorithm is also suggested.

Review of outcome after laparoscopic paraesophageal hiatal hernia repair

Many studies have confirmed the effectiveness of laparoscopic paraesophageal hernia repair, but there are reports of high recurrence rates after surgery. We have conducted a review of the literature to determine whether it is a safe and durable procedure. A literature search was performed to identify all papers relevant to laparoscopic paraesophageal hernia repair. Twenty studies met the inclusion criteria for this review. In total, 1415 patients underwent attempted repair (mean age 65.7 y) of which 94% underwent an antireflux procedure. There were 70 (5.3%) episodes of operative morbidity and 173 (12.7%) patients experienced postoperative complications. In 10 studies, radiologic follow-up was offered after a mean of 16.5 months. Of those undergoing contrast swallow 26.9% had evidence of anatomic recurrence. In conclusion, recurrence rates after laparoscopic repair seem to be high compared with earlier studies of open repair. The long-term consequences of anatomic recurrence are currently uncertain.

Paraesophageal hernia

The laparoscopic repair of paraesophageal hernia has proven to be safe and effective, with relatively low morbidity and mortality rates. The laparoscopic approach is feasible in patients with paraesophageal hernia because these patients are usually past middle age and commonly have multiple other medical problems. The procedure is technically demanding, but skilled laparoscopic surgeons should be able to perform the standard repair, that is, sac excision, crural closure, and fundoplication or gastropexy.

Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach

BACKGROUND

Once paraesophageal hernia has been diagnosed, it should be repaired immediately because of life-threatening complications such as bleeding, ischemia, and perforation when intrathoracic strangulation or volvulus occurs. We describe our surgical strategy for treating this rare type of hiatal hernia with regard to early and late postoperative complications.

STUDY DESIGN

This was a retrospective case series from a university hospital. Twelve patients (seven women and five men) with a mean age of 64 years (range, 50-76 years) and a completely intrathoracic stomach underwent laparoscopic paraesophageal hernia repair. Seven patients had a type 2 hernia, and five patients had a type 3 hernia. Additional organoaxial volvulus was present in three patients. All patients underwent reduction of the stomach and the greater omentum, excision of the hernia sac, closure of the hiatal defect, and a floppy Nissen fundoplication.

RESULTS

Because of severe adhesions, one patient needed an open stomach reduction (conversion rate, 8%). The mean operating time was 161 minutes (range, 110-200 minutes), blood loss was minimal, and the mean postoperative hospital stay was 6 days (range, 4-7 days). There were no intraoperative complications, but early postoperative complications occurred in three patients (25%; one with dysphagia, 1 reoperation due to organoaxial gastric rotation with gastroduodenal obstruction, and one with deep venous thrombosis). No deaths occurred. Followup in all patients is complete, with a mean followup time of 21 months (range, 3-40 months). The complication rate after long-term followup was 8%, and reflux esophagitis symptoms in one patient were completely relieved by medical therapy.

CONCLUSIONS

Laparoscopic paraesophageal hernia repair was feasible and safe with low morbidity and mortality rates in this elderly patient group. To achieve good long-term results, standard surgical treatment should include reduction of the stomach, complete excision of the hernia sac, closure of the hiatal defect, floppy Nissen fundoplication, and anterior gastropexy.

Late results of paraoesophageal hiatus hernia repair with fundoplication

BACKGROUND

Most published reports on results of surgical treatment for paraoesophageal hiatus hernia have been based on patient questionnaires, and seldom included endoscopy or barium meal examinations.

METHODS

Eight pure and 14 mixed-type paraoesophageal hernias were evaluated a median of 37 (range 2-241) months after surgical repair. An antireflux procedure was done in 19 cases. Before operation all had endoscopy or barium meal (20 and 19 patients respectively); after operation 19 had endoscopy and 12 also had barium meal examination. Oesophageal 24 h pH monitoring was done in five cases before surgery, and in 11 afterwards.

RESULTS

Preoperative symptoms of reflux were reported by 18, and were often accompanied by dysphagia, postprandial vomiting or epigastric pain. Symptoms improved after operation, and 21 of the 22 patients were satisfied with the result. At follow-up examination, a recurrent hernia was found in eight of the 19 patients examined. Four of these hernias were sliding, two were mixed type and two purely paraoesophageal.

DISCUSSION

Recurrence of symptoms was associated with persistence of reflux rather than hernia recurrence. Concomitant antireflux procedure is recommended in all operations for mixed-type hiatus hernia, but it should also be considered for purely paraoesophageal hernia if reflux cannot be excluded before operation, or if retro-oesophageal dissection is needed.

Systematic use of gastric fundoplication in laparoscopic repair of paraesophageal hernias

BACKGROUND

Early surgical treatment has been recommended in patients with paraesophageal hiatal hernias. Recently, the laparoscopic approach has emerged as an ideal way to perform the operation. But whether or not an antireflux procedure should be done remains controversial.

PATIENTS AND METHODS

Four patients with type II and eleven with type III hiatal hernias were treated. Twelve of them manifested symptoms of reflux preoperatively. The operative technique consisted of resection of the sac, closure of the crura and gastric fundoplication, anchored to the diaphragm.

RESULTS

All but two patients were completed laparoscopically. Mean operative time was 320 (+/-49 SD) minutes, and mean hospital stay was 3 (+/-1.2 SD) days. Early postoperative complications were subcutaneous emphysema (two patients) and atrial fibrillation (one patient). At one year all patients were asymptomatic without dysphagia, reflux, or recurrence of the hernia.

CONCLUSION

The addition of fundoplication to paraesophageal hernia repair restores competency of the sphincter in patients with reflux associated to the hernia and prevents postoperative gastroesophageal reflux that results from the extensive dissection required. In addition, it provides an ideal means of fixing the stomach in the subdiaphragmatic position, decreasing the long term-risk of recurrence.

Recent developments in upper gastrointestinal surgery

Important changes have occurred in the field of upper gastrointestinal surgery in the past few years. The change with the greatest impact has been the introduction of laparoscopic/thoracoscopic surgery in the treatment of the functional upper gastrointestinal disorders. However, new therapies in such diverse fields as bleeding oesophageal and peptic ulcer disease have greatly lessened the role of the surgeon in the elective setting. Malignant disease of the upper gastrointestinal tract has shown a marked swing away from cancer of the stomach towards cancer in the region of the gastro-oesophageal junction. There remains no consensus on the place of radical surgery in the treatment of these conditions.