Systematic use of gastric fundoplication in laparoscopic repair of paraesophageal hernias

Paraesophageal hernia: to fundoplicate or not?

The need for an antireflux procedure during repair of a paraesophageal hernia (PEH) has been the subject of a long-standing controversy. With most centers now performing routine fundoplication during PEH repair, high-quality data on whether crural repair alone or using a mesh may provide adequate anti-reflux effect is still scarce. We sought to answer to the question: "Is fundoplication routinely needed during PEH repair?". Our endpoints were (I) rates of postoperative gastroesophageal reflux disease (GERD) (either symptomatic or objectively assessed), (II) rates of recurrence, and (III) rates of postoperative dysphagia. We searched the MEDLINE, Cochrane, PubMed, and Embase databases for papers published between 1995 and 2019, selecting comparative cohort studies and only including papers reporting the rationale for performing or not performing fundoplication. Overall, nine papers were included for review. While four of the included studies recommended selective or no fundoplication, most of these data come from earlier retrospective studies. Higher-quality data from recent prospective studies including two randomized controlled trials recommended routine fundoplication, mostly due to a significantly lower incidence of postoperative GERD. However, only a relatively short follow-up of 12 months was presented, which we recognize as an important limitation. Fundoplication did not seem to result in reduced recurrence rates when compared to primary repair alone.

Paraesophageal Hernia Repair: How I Do It

Although the results of a laparoscopic repair of a paraesophageal hernia are convincing and accepted, controversies still persist regarding indications for elective repair, the need for a concurrent fundoplication, the use of mesh, and the need for a Collis gastroplasty. This article is a description of our surgical approach to the patient with a paraesophageal hernia in need of a repair.

Hiatal Hernia Presenting with Recurrent Non-ST Elevation Myocardial Infarction and Cardiac Tamponade

Hiatal hernia is a common pathology, particularly among the elderly or obese populations. Occasionally, markedly dilated hernias can impinge on surrounding structures, notably the heart or lung. In such cases, morbidity can be considerable. We present a case of an enlarging hiatal hernia that compressed the heart, leading to recurrent non-ST elevation myocardial infarction with cardiac tamponade. The patient was successfully managed with nasogastric decompression and surgical repair. We recommend that extrapericardial pathology be considered in tamponade patients with concurrent hiatal hernia and that surgery should be considered the definitive treatment modality.

Minimally invasive surgery for large hiatal hernia

The majority of large hiatal hernias are paraesophageal hiatal hernias (PEH). Once prolapse of the stomach to the chest cavity reaches a high degree, it is called an intrathoracic stomach. More than 25 years have elapsed since laparoscopic surgery was carried out as minimally invasive surgery for PEH. The feasibility and safety thereof has nearly been established. PEH may cause serious complications such as strangulation and perforation. The outcome of elective repair of PEH is better than emergent repair, so we should carry out elective repair as much as possible. Although not a major clinical problem, following PEH repair the rate of anatomical recurrence increases with age. In order to reduce the recurrence rate, mesh reinforcement by crural repair has been widely performed. Although this improves the short-term outcomes, the long-term outcomes are unclear. For PEH repair, fundoplication and gastropexy are believed desirable. We should select the procedure associated with a lower incidence of dysphagia and so on following surgery. While relaxing incision is useful for primary tension-free closure, it has not contributed to improvement in the recurrence rate.

Evidence-Based Practice Guideline for Surgical Treatment of Gastroesophageal Reflux Disease 2018

The prevalence of gastroesophageal reflux disease (GERD) is increasing in Korea, and physicians, including surgeons, have been focusing on its treatment. Indeed, in Korea, medical treatment using a proton pump inhibitor is the mainstream treatment for GERD, while awareness of surgical treatment is limited. Accordingly, to promote the understanding of surgical treatment for GERD, the Korean Anti-Reflux Surgery Study Group published the Evidence-Based Practice Guideline for the Surgical Treatment of GERD. The guideline consists of 2 sections: fundamental information such as the definition, symptoms, and diagnostic tools of GERD and a recommendation statement about its surgical treatment. The recommendations presented 5 debates regarding fundoplication: 1) comparison of the effectiveness of medical and surgical treatments, 2) effectiveness of surgical treatment in cases of refractory GERD, 3) effectiveness of surgical treatment of extraesophageal symptoms, 4) comparison of effectiveness between total and partial fundoplication, and 5) effectiveness of fundoplication in cases of hiatal hernia. The present guideline is the first to demonstrate the efficacy of the surgical treatment GERD in Korea.

Treatment of paraesophageal hiatal hernia in octogenarians: a systematic review and retrospective cohort study

Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising 'surgery,' 'paraesophageal hiatal hernia,' and 'octogenarians.' Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II-IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population.

Paraesophageal Hernia and Reflux Prevention: Is One Fundoplication Better than the Other?

BACKGROUND

The management of paraesophageal hernia (PEH) is one of the most debated in surgery. Trends regarding indications, approach (open, laparoscopic, thoracoscopic), sac excision, mesh placement, and routine performance of fundoplication have changed over time. Today, most surgeons tend to perform a laparoscopic PEH repair that entails the excision of the sac, liberal use of a mesh to buttress the hiatus, and the addition of an anti-reflux procedure. Nevertheless, very little has been written on which type of fundoplication should be performed in these patients. Therefore, the goal of our study was to provide an evidence-based overview of which type of fundoplication should be performed during a PEH repair and the role of preoperative function tests in the decision-making METHODS: We searched the MEDLINE, Cochran, PubMed, Google Scholar, and Embase databases for papers published between 1996 and 2016 pertaining to the surgical treatment of PEH. We hand-searched the bibliographies of included studies and we excluded all reviews and case reports. We selected clinical studies and technical reports. We only considered papers stating rationales for the type of fundoplication performed.

RESULTS

Our search yielded 24 articles: 17 clinical studies and 7 technical reports. In five of the clinical studies, a fundoplication was added only to patients with reflux symptoms. In all clinical studies, the most performed procedure was a total fundoplication (Nissen or Nissen-Rossetti), whereas a partial fundoplication (Toupet more frequently than Dor) or no fundoplication was reserved to those with impaired esophageal motility. All seven technical reports recommended a tailored approach and suggested adding a partial fundoplication (mainly Toupet) when the manometric findings showed esophageal dismotility.

CONCLUSION

The argument of whether or not a fundoplication should be added to a PEH repair in patients without evidence of reflux still persists. However, this review highlights that, when a fundoplication is performed, a tailored approach based on preoperative function tests is almost always preferred.

Long-Term Patient-Reported Outcomes of Paraesophageal Hernia Repair

Background and Objectives:

There is a lack of consensus on the optimal repair technique and the definition of good outcomes in paraesophageal hernia (PEH) repair. We reviewed long-term patient-reported outcomes of open and laparoscopic PEH repair to assist with our future surgical consent process.

Methods:

This was a retrospective case–control study including all patients with PEH repair performed from 2000 through 2012 at a single center without the use of mesh. We mailed questionnaires to patients to assess reoperation, symptom control, and satisfaction.

Results:

Chart review identified 217 patients who underwent PEH repair. Nineteen died during the follow-up period. Of the 106 returning the questionnaire, 87 underwent laparoscopic repair, and 19 had open repair, with follow-up of 6.6 (SD 3.9) years and 7.0 (SD 4.1) years, respectively. Reoperation rates were 9.9% and 5.3%, respectively (P = .720). Dysphagia, heartburn, and regurgitation improved in 95.4% of patients after laparoscopic repair and 89.5% after open repair (P = .318). Medication for symptom control was necessary in 54.0% of patients after laparoscopic repair and 26.3% after open repair (P = .029). In each group, 90% stated that they would still choose to have the operation (P = .713).

Conclusions:

Long-term patient-specific outcomes showed comparable, encouraging results between open and laparoscopic repair of PEH without mesh reinforcement. However, half of those undergoing laparoscopic repair required the use of medication for symptom control. This study adds to the literature describing long-term patient-specific outcomes and can be useful when counseling patients about PEH repair.

A Rare Case of Bochdalek Hernia with Concomitant Para-Esophageal Hernia, Repaired Laparoscopically in an Octogenarian

Patient: Male, 81

Final Diagnosis: Bochdalex hernia

Symptoms: Chest pain • vomiting

Medication: —

Clinical Procedure: Laparoscopic repair of both diaphragmatic hernias

Specialty: Surgery

Long-term clinical outcomes after intrathoracic stomach surgery: a decade of longitudinal follow-up

BACKGROUND

A subset of patients with large paraesophageal hernias have more than 75% of the stomach herniated above the diaphragm; such cases are referred to as intrathoracic stomach (ITS). Herein, we report longitudinal symptomatic outcomes over a decade after surgical ITS repair in a large patient cohort.

METHODS

Patients who underwent surgical treatment for ITS from 01/2004 to 05/2016 were studied. Preoperative and follow-up data were prospectively collected. Patients completed a standardized symptom questionnaire 1 year postoperatively and at 2-year intervals thereafter.

RESULTS

In total, 235 patients were reviewed. The mean age was 70.0 ± 11.6 years; 174 patients (74.0%) were women. Surgical procedures included 7 transthoracic repairs and 228 transabdominal repairs (222 laparoscopic, 2 open, 4 laparoscopic-to-open conversions). Anti-reflux procedures were performed in 173 patients (73.6%). 33 patients (14.0%) had mesh reinforcement of hiatal closure; 11 (4.7%) underwent Collis gastroplasty. Follow-up symptom questionnaires at 1, 3, 5, 7, 9, and 11 years were available for 81, 48, 47, 30, 33, and 38% of patients, respectively. Significant and lasting symptom improvement was reported at all follow-up time points. Mean satisfaction scores of 9.3, 9.1, 9.3, 9.0, 9.5, and 9.8 on a 1-10 scale were recorded at the aforementioned intervals.

CONCLUSIONS

Long-term clinical outcomes confirm that laparoscopic ITS repair is safe and durable, and is associated with a high degree of patient satisfaction and symptom resolution.

Favorable results from a prospective evaluation of 200 patients with large hiatal hernias undergoing LINX magnetic sphincter augmentation

Introduction

Magnetic sphincter augmentation (MSA) of the lower esophageal sphincter restores the antireflux barrier in patients with hiatal hernias ≤3 cm. We performed a prospective study in patients undergoing MSA with the LINX device during repair of paraesophageal and hernias over 3 cm axial component.

Methods and procedures

Multicenter, prospective study of consecutive patients treated with MSA at the time of repair of hiatal hernias >3 cm.

Results

200 patients (110 female) were treated between March 2014 and February 2017 via laparoscopic hernia repair and MSA. Mean age was 59.5 years, mean BMI 29.4. 40% had esophagitis, 20% intestinal metaplasia, 72 of 77 tested had abnormal pH studies. Preoperative PPI use was reported by 87%. Eighteen patients had prior hiatal hernia/fundoplication. All had normal function. 78% of patients had axial hiatal hernia ≥5 cm or large paraesophageal component. Mean operative time was 81 min (38–193), EBL was 10 cc. Non-permanent mesh reinforcement of hiatal repair was performed in 83% of the patients. There were two readmissions for dehydration; 2 patients with pulmonary embolism, and 1 patient with cardiac ischemia. Nineteen patients required dilation. 156 pts were followed at a median of 8.6 months. GERD-HRQL scores improved from 26 preoperatively to 2 postoperatively. Complete PPI independence was achieved in 94% (147/156). Videoesophagram in 51 patients at median 11 months found 3 asymptomatic hernias <3 cm. One symptomatic patient underwent successful repair of the hernia without MSA manipulation. There have been no device explants, erosions, or migrations to date.

Conclusions

This prospective study of 200 patients with >3 cm hernias undergoing MSA with hiatoplasty resulted in favorable outcomes with median of 9 months follow-up. Comparing this to published reports of MSA in patients with <3 cm hernias, the safety and clinical efficacy of MSA are independent of initial hernia size.

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.

Laparoscopic surgical treatment of esophageal hiatal hernia

Types II, III and IV esophageal hiatal hernia (EHH) which presents obvious symptoms or leads to potentially fatal complications requires surgical treatment. Laparoscopy has been used to repair EHH in the last two decades globally and proved to be minimally invasive compared to conventional open surgery. This review summarizes current status and prospectives of laparoscopic application in EHH treatment. The published articles on minimally invasive laparoscopic surgical treatment of EHH in PubMed, Cochrane Library and EMBASE databases were retrieved and analyzed. From 1992 to 2015, 86 English articles involving a total of 4771 patients receiving laparoscopic treatment for EHH were retrieved. Perioperative information including safety and feasibility of procedure, postoperative complications, and short/long-term outcome after laparoscopic repair was retrospectively analyzed. Laparoscopic surgical treatment of EHH is a safe, feasible and minimally invasive procedure with fast recovery after repair, low postoperative morbidity and recurrence.

Robotic-Assisted Paraesophageal Hernia Repair: Initial Experience at a Single Institution

BACKGROUND

Laparoscopic surgery is considered the standard approach for the treatment of paraesophageal hernias (PEHs). Despite its advantages, this approach is technically demanding with a significant learning curve. Data about the safety and utility of the robotically assisted paraesophageal hernia repair (RA-PEHR) are scarce. The aim of this study is to assess the feasibility and safety of robotic assistance for the treatment of PEH.

MATERIALS AND METHODS

Between June 2010 and December 2015, patients who underwent elective RA-PEHR were included in a prospectively collected database. Demographic data, American Society of Anesthesiologists (ASA) classification, preoperative testing, operative time (OT), length of hospital stay (LOS), conversion rate, morbidity, and mortality were recorded and reviewed retrospectively.

RESULTS

Sixty-one patients underwent RA-PEHR with mesh, 72% were female (mean age of 63 and mean body mass index [BMI] of 30). ASA classification was 2.6 (57% of patients had an ASA III). With respect to the type of the hernia, the preoperative diagnosis was: Type II 26%, III 64%, and IV 13%. OT averaged 186 minutes (88-360), including robot setup time. After the 16th case, OT significantly decreased by 4.09 minutes (P = .01). There were no conversions. The average blood loss was 51 mL. Perioperative complications, including intraoperative and 30-day complications, were 6% and 23%, respectively. The mean length of hospitalization was 2.6 (1-18) days. There were no deaths. Forty patients (66%) were available for follow-up, and length of follow-up was 17 ± 15 months. Anatomic recurrence was observed in 42% of patients and only 23% of patients were symptomatic.

CONCLUSIONS

This report represents the largest series to date of RA-PEHR. RA-PEHR has proved to be feasible and safe with a learning curve comparable to the standard laparoscopic approach.

Treatment and controversies in paraesophageal hernia repair

Background

Historically all paraesophageal hernias were repaired surgically, today intervention is reserved for symptomatic paraesophageal hernias. In this review, we describe the indications for repair and explore the controversies in paraesophageal hernia repair, which include a comparison of open to laparoscopic paraesophageal hernia repair, the necessity of complete sac excision, the routine performance of fundoplication, and the use of mesh for hernia repair.

Methods

We searched Pubmed for papers published between 1980 and 2015 using the following keywords: hiatal hernias, paraesophageal hernias, regurgitation, dysphagia, gastroesophageal reflux disease, aspiration, GERD, endoscopy, manometry, pH monitoring, proton pump inhibitors, anemia, iron-deficiency anemia, Nissen fundoplication, sac excision, mesh, and mesh repair.

Results

Indications for paraesophageal hernia repair have changed, and currently symptomatic paraesophageal hernias are recommended for repair. In addition, it is important not to overlook iron-deficiency anemia and pulmonary complaints, which tend to improve with repair. Current practice favors a laparoscopic approach, complete sac excision, primary crural repair with or without use of mesh, and a routine fundoplication.

Robotic giant hiatal hernia repair: 3 year prospective evaluation and review of the literature

BACKGROUND

While conventional laparoscopic repair for giant hiatal hernias is considered difficult, robotic technology is likely to result in an improved postoperative course.

METHODS

We prospectively analysed patients with giant hiatal hernias who underwent robotic repair during a 3 year period. Preoperative data, operative variables, complications, clinical outcomes and anatomical recurrence after 1 year were evaluated.

RESULTS

Six patients with giant hiatal hernias underwent robotic repair using the Da Vinci surgical system. The mean operative time was 182 min. The mean hospital stay was 6 days. No patients required reoperation for disease recurrence, and all claimed the absence of postoperative symptoms.

CONCLUSIONS

Robotic approaches can minimize surgical trauma in patients with giant hiatal hernias and result in favourable outcomes in terms of anatomical recurrence and quality of life. With the availability of the da Vinci System, all patients with giant hiatal hernias can be offered a minimally invasive surgical option.

Laparoscopic treatment of type III and IV hiatal hernia - authors' experience

Introduction

There are four types of hiatal hernias, and diagnosis is established on the basis of gastroscopy in the majority of cases. Type III represents a mixed type in which the abdominal esophagus as well as the gastric cardia and fundus protrude into the thorax through the pathologically widened esophageal hiatus. Type IV, the so-called upside down stomach, can be considered an evolutionary form of type III, and refers to herniation of nearly the whole stomach (except for the cardia and pylorus) into the thorax. Types III and IV of hiatal hernias represent a group of rare diaphragmatic defects; thus, most centers do not possess considerable experience in their treatment. Frequently, laparoscopic treatment is implemented, although, according to some authors, conversion to laparotomy, thoracotomy, or thoracolaparotomy is necessary in selected cases.

Aim

To analyze the outcomes of laparoscopic treatment of the largest hiatal hernias, i.e. type III and IV hernias.

Material and methods

A total of 25 patients diagnosed with type III and IV hiatal hernia were included in further analysis.

Results

As many as 19 out of 25 patients (76%) assessed the outcome of the surgery as evidently positive and reported marked improvement in the quality of life.

Conclusions

The laparoscopic technique constitutes an excellent and safe method of repair of even the most complex defects in the esophageal hiatus. Therefore, the minimally invasive technique combined with an anti-reflux procedure should be the method of choice in patients with type III and IV hernia.

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.

The Need for Fundoplication at the Time of Laparoscopic Paraesophageal Hernia Repair

Most authors recommend an antireflux operation at the time of laparoscopic paraesophageal hernia (PEH) repair. A fundoplication combats the potential postoperative reflux resulting from disruption of the hiatal anatomy and may minimize recurrence. The purpose of this study is to evaluate the differences in postoperative dysphagia, reflux symptoms, and hiatal hernia recurrence in patients with and without a fundoplication at the time of laparoscopic paraesophageal hernia repair. Patients undergoing laparoscopic PEH repair from July 2006 to June 2012 were identified. Open repairs and reoperative cases were excluded. Patient characteristics, operative details, complications, and postoperative outcomes were recorded. Over the six-year period, 152 laparoscopic PEH repairs were performed. Mean age was 65.8 years (range, 31 to 92) and average body mass index was 29.9 kg/m2 (range, 18 to 52 kg/m2). Concomitant fundoplication was performed in 130 patients (86%), which was determined based on preoperative symptoms and esophageal motility. Mean operative times were similar with fundoplication (188 minutes) and without (184.5 minutes). At a mean follow-up of 13.9 months, there were 19 recurrences: 12.3 per cent (16 of 130) in the fundoplication group and 13.6 per cent (three of 22) in those without. Dysphagia lasting greater than six weeks was present in eight patients in the fundoplication group (6.2%) and in none in those without ( P = 0.603). Eighteen percent of patients without a fundoplication reported postoperative reflux compared with 5.4 per cent of patients with a fundoplication ( P = 0.055). In the laparoscopic repair of PEH, the addition of a fundoplication minimizes postoperative reflux symptoms without additional operative time. Neither dysphagia nor hiatal hernia recurrence is affected by the presence of a fundoplication.

Modern treatment of paraesophageal hernia: preoperative evaluation and technique for laparoscopic repair

This article reviews the preoperative evaluation of patients with paraesophageal hernia (PEH) and details the principles and components of a laparoscopic PEH repair. Complete hernia sac dissection and excision, adequate esophageal mobilization, reapproximation of the crura, and creation of an antireflux barrier make up the key steps in any repair and are described. Although the preferred operative approach to PEH has undergone significant modification, especially since the introduction of minimally invasive laparoscopic techniques, many controversies still exist. The decision of whether to use mesh to reinforce the crural closure remains an unresolved issue in the surgical literature, and further evolution in this and other areas of PEH surgery is sure to occur in the near future.

How I do it: laparoscopic paraesophageal hernia repair

INTRODUCTION

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

TECHNIQUE

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

CONCLUSION

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

Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes

OBJECTIVE

We recently reported in a multi-institutional, randomized study of laparoscopic paraesophageal hernia repair (LPEHR) that the anatomic recurrence rate at a median of approximately 5 years was >50%. This study focuses exclusively on the symptomatic response to LPEHR and its relationship with the development of a recurrent hernia.

METHODS

During 2002 to 2005, 108 patients underwent LPHER with or without biologic mesh. A standardized symptom severity questionnaire, SF-36 health survey, and upper gastrointestinal series were performed at baseline, 6 months, and during 2008-2009.

RESULTS

Of 108 patients, 72 (average age of 68 ± 10 years) underwent clinical assessment, and 60 of them also had radiologic studies at a median follow-up of 58 (40-78) months. Radiographic recurrence (≥ 20 mm) was 14% at 6 months and 57% at the time of follow-up, and the average recurrence size was 40 ± 10 mm. All symptoms were significantly improved at long-term follow-up and, with the exception of heartburn, were unaffected by the presence or size of the recurrence. Two patients (3%) with recurrent symptoms related to their hernia underwent reoperation.

CONCLUSION

Despite frequent radiologic recurrences after LPEHR, symptoms remain well controlled, patient satisfaction is high, and the need for reoperation is low.

Laparoscopic paraesophageal hernia repair with acellular dermal matrix cruroplasty

This study suggests that laparoscopic paraesophageal hernia repair with acellular dermal matrix Cruroplasty is an effective method of repairing symptomatic paraesophageal hernias with a low perioperative morbidity.

Background:

Laparoscopic paraesophageal hernia repair (LPEHR) has been shown to be both safe and efficacious. Compulsory operative steps include reduction of the stomach from the mediastinum, resection of the mediastinal hernia sac, ensuring an appropriate intraabdominal esophageal length, and crural closure. The use of mesh materials in the repair of hiatal hernias remains controversial. Synthetic mesh may reduce hernia recurrences, but may increase postoperative dysphagia and result in esophageal erosion. Human acellular dermal matrix (HADM) may reduce the incidence of hernia recurrence with reduced complications compared with synthetic mesh.

Methods:

A retrospective review of all cases of laparoscopic hiatal hernia repair using HADM from December 2008 through March 2010 at a single institution was performed evaluating demographic information, BMI, operative times, length of stay, and complications.

Discussion:

Forty-six LPEHRs with HADM were identified. The mean age of patients was 60.3 years (±13.9); BMI 30.3 (±5.3); operative time 182 minutes (±56); and length of stay 2.6 days (±1.9). Nine of 46 (19.6%) patients experienced perioperative complications, including subcutaneous emphysema without pneumothorax (n=2), urinary retention (n=1), COPD exacerbation (n=2), early dysphagia resolving before discharge (n=1), esophageal perforation (n=1), delayed gastric perforation occurring 30 days postoperatively associated with gas bloat syndrome (n=1), and PEG site abscess (n=1). There were 2 clinically recurrent hernias (4.3%). Radiographic recurrences occurred in 2 of 26 patients (7.7%). Six of 46 (13%) patients reported persistent dysphagia.

Conclusion:

LPEHR with HADM crural reinforcement is an effective method of repairing symptomatic paraesophageal hernias with low perioperative morbidity. Recurrences occur infrequently with this technique. No mesh-related complications were seen in this series.

Experience of laparoscopic paraesophageal hernia repair at a single institution

BACKGROUND

Paraesophageal hernia patients are often elderly with complicating medical comorbidities, making surgical management complex in formulating a management strategy.

METHODS

Between January 2005 and July 2009, 93 patients underwent surgical treatment of paraesophageal hernia, including 8 recurrent cases after multiple repairs. Open transabdominal surgeries were performed in 14 (15%) patients, and combined thoracotomy was performed in 1 (1%). Laparoscopic surgeries were performed in 78 (84%) patients with 4 (5%) conversions. Artificial prosthetics were used in 27 (29%) patients. Fundoplication was performed in 82 (88%) patients. Gastropexy or feeding tube gastrostomy was performed in 10 (11%) patients.

RESULTS

The average length of the surgery was 125 minutes (range, 51-304 min). The mean blood loss was 100 mL. The average length of stay was 4 days (range, 1-14 d). There were 2 mortalities (2%) and 4 re-operations, with a recurrence rate of 2%.

CONCLUSIONS

Laparoscopic paraesophageal hernia repair can be performed safely with acceptable results when following a standard approach.

Tailored or routine addition of an antireflux fundoplication in laparoscopic large hiatal hernia repair: a comparative cohort study

Background

There is controversy about the tailored or routine addition of an antireflux fundoplication in large hiatal hernia (type II–IV) repair. We investigated the strategy of selective addition of a fundoplication in patients with a large hiatal hernia and concomitant gastroesophageal reflux disease.

Methods

Between 2002 and 2008, 60 patients with a large hiatal hernia were evaluated preoperatively and 12 months after surgery by reflux-related symptoms, upper endoscopy, and esophageal 24-h pH monitoring. In patients with preoperatively documented gastroesophageal reflux disease, an antireflux fundoplication was added during hiatal hernia repair.

Results

An antireflux procedure was added in 35 patients and 25 patients underwent hiatal hernia repair only. Preoperative symptoms were improved or resolved in 31 patients (88.6%) in the group who had fundoplication and in 20 patients (87.0%) in the group who did not have fundoplication. In patients with fundoplication, esophagitis was present in 6 patients (22.2%) after surgery and abnormal esophageal acid exposure persisted in 11 (39.3%). Seven patients (38.9%) with hernia repair only developed abnormal esophageal acid exposure, and esophagitis was postoperatively generated in five (27.8%). In neither group did patients have new onset of daily heartburn or dysphagia.

Conclusions

In patients with a large hiatal hernia associated with gastroesophageal reflux disease, addition of a fundoplication during hernia repair yields acceptable reduction of symptoms and does not generate symptomatic side effects. Objective control of reflux, however, is only moderate. Omission of an antireflux procedure in the absence of gastroesophageal reflux disease induced esophagitis in 28% and abnormal esophageal acid exposure in 39% of patients. Therefore, routine addition of an antireflux fundoplication should be recommended.

Laparoscopic repair of esophageal hiatal hernia

This study was to appraise safety and feasibility of laparoscopic approach and investigate the clinical effects of laparoscopic tension-free repair of esophageal hiatal hernia using mesh. From August 2006 to July 2009, 24 patients with esophageal hiatal hernia underwent laparoscopic repair. Twenty-three patients received laparoscopic tension-free repair using mesh, at the same time, Toupet or Dor partial fundoplication was performed. One patient was converted to open surgery. The average operating time was 90 min (70-210 min) and the blood loss was between 10-110 mL. There was no death. The mean postoperative hospital stay was 5 days (3-30 days). During a follow-up period of 12-20 months (mean 15 months), there was no recurrence of the hernia, and no complication with use of mesh. The present study suggested that laparoscopic approach was secure and minimally invasive operation for esophageal hiatal hernia and the use of mesh could reduce recurrence rate.

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.

Mesh erosion as a complication of laparoscopic fundoplication with prosthetic hiatal closure: report of a case

BACKGROUND

Laparoscopic fundoplication has become the standard procedure for surgical management of gastroesophageal reflux disease. Simple cruroplasty is associated with a high recurrence rate and most authors recommend the use of prosthetic meshes for crural closure.

METHODS

Herein we report a patient who was admitted with the complaint of severe dysphagia a year after laparoscopic fundoplication with prosthetic hiatal closure.

RESULTS

The patient presented with mesh erosion into the esophagus and required a distal esophageal resection.

CONCLUSIONS

This case demonstrates that appropriate surgical technique is important for preventing mesh-related complications. A small-sized mesh should be placed so as to have no contact with the esophagus and should be secured sufficiently to the diaphragmatic crura to avoid the potential complications of mesh reinforcement.

Outcomes after repair of the intrathoracic stomach: objective follow-up of up to 5 years

INTRODUCTION

Laparoscopic surgery is a viable treatment option for intrathoracic stomach (ITS); however, doubts have been raised regarding its efficacy. Routine use of mesh has been advocated. The aim of this study is to look at long-term objective and symptomatic outcomes after repair of ITS with selective use of mesh and fundoplication.

MATERIALS AND METHODS

A retrospective review of prospectively collected data was performed for patients who underwent surgical treatment of ITS from January 2004 to April 2009. ITS was defined as herniation of greater than 75% of the stomach into the chest on barium swallow. A standardized foregut symptom questionnaire was administered along with contrast study at 1, 3, and 5 years post surgery.

RESULTS

Seventy-three patients with intrathoracic stomach were included in the study. Mean age was 70.6±10.4 (44-88) years, and two-thirds were females. There were 7 transthoracic and 66 transabdominal repairs (64 laparoscopic, 1 open, and 1 laparoscopic to open conversion). There was one intraoperative death, due to bleeding. Antireflux surgery was performed in 43 patients (20 Nissen, 18 Toupet, 1 Dor, and 4 Roux-en-Y gastric bypass (RNYGB)). Ten patients had Collis gastroplasty for short esophagus. Mesh was used in ten (13.7%) patients for crus reinforcement. Objective follow-up was available for 88%, 78%, and 92% patients at 1, 3, and 5 years, respectively. There were 5% (3/61), 11% (4/36), and 17% (2/12) radiological failures at these intervals. There was no significant difference in mean symptom and satisfaction scores or use of proton pump inhibitor (PPI) between patients with and without antireflux surgery. Mean satisfaction scores were 9.1, 9.0, and 9.0 at 1, 3, and 5 years, respectively.

CONCLUSION

Laparoscopic repair of ITS with selective use of mesh and fundoplication is feasible, safe, and durable, resulting in a high degree of patient satisfaction.

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.

Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score and operation type influence morbidity

BACKGROUND

Patients undergoing laparoscopic paraesophageal hernia (PEH) repair risk substantial morbidity. The aim of the present study was to analyze predictive factors for postoperative morbidity and mortality.

METHODS

A total of 354 laparoscopic PEH repairs were analyzed from the database of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTS). Age (<70 and > or =70 years) and risk (low: American Society of Anesthesiologists (ASA) scores 1 + 2; high ASA scores 3 + 4) groups were defined and multivariate logistic regression was conducted.

RESULTS

In patients > or =70 years of age postoperative morbidity (24.4% versus 10.1%; p = 0.001) and mortality (2.4% versus 0%; p = 0.045) were significantly higher than in patients <70 years of age. In patients with gastropexy, this significant age difference was again present (38.8% versus 10.5%; p = 0.001) whereas in patients with fundoplication no difference between age groups occurred (11.9% versus 10.1%; p = 0.65). Mortality did not differ. High-risk patients had a significantly higher morbidity (26.0% versus 11.2%; p = 0.001) but not mortality (2.1% versus 0.4%; p = 0.18). The multivariate logistic regression identified the following variables as influencing postoperative morbidity: Age > or =70 years (Odds Ratio [OR] 1.99 [95% CI 1.06 to 3.74], p = 0.033); ASA 3 + 4 (OR 2.29 [95% Confidence Interval (CI) 1.22 to 4.3]; p = 0.010); type of operation (gastropexy) (OR 2.36 [95% CI 1.27 to 4.37]; p = 0.006).

CONCLUSIONS

In patients undergoing laparoscopic paraesophageal hernia repair age, ASA score, and type of operation significantly influence postoperative morbidity and mortality. Morbidity is substantial among elderly patients and those with co-morbidity, questioning the paradigm for surgery in all patients. The indication for surgery must be carefully balanced against the individual patient's co-morbidities, age, and symptoms, and the potentially life threatening complications.

Severe complication of laparoscopic mesh hiatoplasty for paraesophageal hernia

BACKGROUND

Several studies have shown that laparoscopic hernia repair for large paraesophageal hiatal hernia is associated with a high recurrence rate. Therefore, some authors recommend the use of prosthetic meshes. Considering the dynamic area between the esophagus and the diaphragmatic crura with its constant motion, it is astonishing that only a minor number of surgeons describe mesh-associated complications.

METHODS

Between January 2000 and August 2008, 26 patients of the Centre Hospitalier Emile Mayrisch (CHEM, Luxembourg) underwent laparoscopic repair for large paraesophageal hiatal hernia (median age, 70 (range, 39-90) years). In nine patients, prosthetic mesh reinforcement was performed (7 composite/2 mono-phase mesh). Crural repair without tension was performed only with sutures. There were no conversions. Follow-up assessment was prospective with the GIQL (Gastro-Intestinal Quality of Life) Index.

RESULTS

Responses to the GIQLI questionnaires were obtained from 20 patients (6 died of unrelated causes). Nineteen patients were satisfied with their symptom control 1 year after the operation (GIQLI 127). Sixteen patients had radiological follow-up (median, 24 months). Three patients treated without mesh (3/10) showed a radiological recurrence. All of them (3/10) had symptoms. None of the controlled patients with mesh (0/6) showed a recurrence. One patient developed a severe aortal bleeding 1, 2, and 3 weeks after the laparoscopic mono-phase mesh repair. During conventional operation, the bleeding stopped. Three years later, the follow-up showed a satisfied patient (GIQLI 127).

CONCLUSIONS

In view of the described complication, there is still considerable controversy regarding the routine use of mesh. To increase safety, a composite mesh should be preferred.

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.

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.

Is a circular polypropylene mesh appropriate for application at the esophageal hiatus? Results from an experimental study in a porcine model

BACKGROUND

Mesh reinforcement in hiatal hernia surgery is debated. Randomized controlled trials have shown that recurrences may be reduced, but there is also the fear of mesh-related complications. Experimental studies on the characteristics of specific mesh types with regard to the risk of such complications are rare. The current study aimed to investigate the properties of a circular heavy-weight polypropylene mesh in terms of stenosis, migration, erosions, and adhesions in a porcine model.

METHODS

A 55 x 55-mm heavy-weight polypropylene mesh with a 16.5-mm eccentric hole for the esophagus corresponding to a calculated mesh area of 2811 mm(2) and a hole area of 214 mm(2) were implanted in nine German Landrace pigs. Six weeks later, the meshes were explanted and investigated for size, shrinkage, migration and adhesions.

RESULTS

The total mesh area shrank to a mean of 2,040 +/- 178 mm(2) (p < 0.001), and the hole for the esophagus showed a trend toward an increase to 239 +/- 38 mm(2) (p = 0.108). In not a single location did the mesh overhang the hiatal margin. The mean distance of retraction from the hiatal margin was 4.3 +/- 2.8 mm. Therefore, no stenoses, migrations, or erosions occurred.

CONCLUSIONS

A circular heavy-weight polypropylene mesh seems to be appropriate for the application at the esophageal hiatus in terms of safety and stability. This means that it is characterized by a position-stable centered fixation around the esophagus without a tendency toward stenosis, migration, or erosion.

Laparoscopic repair of paraesophageal hernia requires cautious enthusiasm

The article tries to address the dilemma confronting the repair of paraesophageal hernia (PEH). The case has been made for repair upon diagnosis. The initial results of laparoscopic repair were projected as successful. However, recurrence and reflux have plagued many studies. Whereas adjunct fundoplication is now consistently performed by most surgeons, the basis is uncertain. Recurrence rate is often higher than that reported if only the 'imaged' follow-up patients are considered. Esophageal lengthening is believed to potentially benefit both the hallmark complications. The worldwide experience with laparoscopic esophageal lengthening is scanty (although it was not uncommon in the days of open surgery). Compared to the open repair, the laparoscopic method has a higher recurrence rate, higher major specific complication rate, comparable symptom outcome and a shorter hospital stay.

Efficacy of laparoscopic mesh-augmented hiatoplasty in GERD and symptomatic hiatal hernia. Study using combined impedance-pH monitoring

BACKGROUND

Laparoscopic fundoplication is the standard antireflux procedure. However, side effects such as gas bloating indicate that the procedure is not unproblematic. Laparoscopic mesh-augmented hiatoplasty (LMAH) might be an alternative operation aimed at restoring the intra-abdominal part of the esophagus and reducing the size of the diaphragmatic hiatus.

AIM

The aim of this study was to prospectively evaluate gastroesophageal reflux disease symptoms and gastroesophageal reflux before and after LMAH using 24 h impedance-pH monitoring (MII-pH).

MATERIALS AND METHODS

Twenty patients underwent MII-pH monitoring pre- and 3 months post-LMAH. Symptoms were assessed using the Gastrointestinal Symptom Rating Scale questionnaire.

RESULTS

LMAH reduced the mean (SD) reflux syndrome score [pre-op 4.5 (1.7) vs post-op 1.4 (0.9); p<0.001], median (25th-75th percentile) distal %time pH<4 [4.9 (3.4-10.3) vs 1.0 (0.3-2.5) %; p=0.001) and total number of liquid reflux episodes [27.5 (17.5-38.3) vs 18 (7.3-29.3); p<0.05] without changing the number of gas reflux episodes [12 (6-34.3) vs 13.5 (6-20); p=0.346). All patients reported no limitation of their ability to belch.

CONCLUSION

LMAH significantly reduces reflux symptoms and esophageal acid exposure without interfering with the ability to vent gas from the stomach documented by an unchanged number of gas reflux episodes before and after LMAH.

Complications of PTFE mesh at the diaphragmatic hiatus

Paraesophageal hernia repair has been associated with a recurrence rate of up to 42%. Thus, in the last decade, there has been increasing interest in the use of mesh reinforcement of the hiatal repair. Polytetrafluoroethylene (PTFE) is one of the materials that have been used for this purpose, as it is thought to induce minimal tissue reaction. We report two cases in which complications specific to the use of PTFE mesh in this location developed over time. In the first patient, a gastrectomy was required to remove a large PTFE mesh which had eroded into the esophagogastric junction and gastric cardia. The second patient experienced severe dysphagia resulting from a stricture caused by the implant, requiring removal of the mesh. Although such complications have only rarely been reported, the severity and consequences of these incidents, as reported in the literature and in light of our observations, suggest that an alternative to PTFE should be considered for crural reinforcement during paraesophageal hernia repair.