Laparoscopic Repair of Paraesophageal Hernias

Abstract

Background and Objectives:Laparoscopy has quickly become the standard surgical approach to repair paraesophageal hernias. Although many centers routinely perform this procedure, relatively high recurrence rates have led many surgeons to question this approach. We sought to evaluate outcomes in our cohort of patients with an emphasis on recurrence rates and symptom improvement and their correlation with true radiologic recurrence seen on contrast imaging.Methods:We retrospectively identified 126 consecutive patients who underwent laparoscopic repair of a large paraesophageal hernia between 2000 and 2010. Clinical outcomes were reviewed, and data were collected regarding operative details, perioperative and postoperative complications, symptoms, and follow-up imaging. Radiologic evidence of any size hiatal hernia was considered to indicate a recurrence.Results:There were 95 female and 31 male patients with a mean age (± standard deviation) of 71 ± 14 years. Laparoscopic repair was completed successfully in 120 of 126 patients, with 6 operations converted to open procedures. Crural reinforcement with mesh was performed in 79% of patients, and 11% underwent a Collis gastroplasty. Fundoplications were performed in 90% of patients: Nissen (112), Dor (1), and Toupet (1). Radiographic surveillance, obtained at a mean time interval of 23 months postoperatively, was available in 89 of 126 patients (71%). Radiographic evidence of a recurrence was present in 19 patients (21%). Reoperation was necessary in 6 patients (5%): 5 for symptomatic recurrence (4%) and 1 for dysphagia (1%). The median length of stay was 4 days.Conclusion:Laparoscopic paraesophageal hernia repair results in an excellent outcome with a short length of stay when performed at an experienced center. Radiologic recurrence is observed relatively frequently with routine surveillance; however, many of these recurrences are small, and few patients require correction of the recurrence. Furthermore, these small recurrent hernias are often asymptomatic and do not seem to be associated with the same risk of severe complications developing as the initial paraesophageal hernia.

Increasing rate of para‐oesophageal hiatus hernia surgical repair within Australia

“…Surgeons are more competent and confident in PEH laparoscopic surgical repair with reduced peri-operative morbidity and improved outcomes, 26 but increased exposure and better training in this advanced procedure, such as through the Australian and New Zealand Gastric and Oesophageal Surgery Association fellowships, will improve access to this difficult procedure. This rise will be multifactorial.…”

“…It may indicate increasing PEH hernia rates, increased diagnosis and investigation (either due to symptoms or incidental) or more likely the increase in surgical laparoscopic capability. Surgeons are more competent and confident in PEH laparoscopic surgical repair with reduced peri-operative morbidity and improved outcomes, 26 but increased exposure and better training in this advanced procedure, such as through the Australian and New Zealand Gastric and Oesophageal Surgery Association fellowships, will improve access to this difficult procedure. Future studies will need to be conducted to evaluate the possibility of increased incidence of PEH and its relation to the rise in risk factors within Australia.…”

“…26 In 2016, TAS had the highest prevalence (67.7%) 21 of overweight or obese people, and the highest proportion of older people (19%), 20 whereas WA had the lowest prevalence of overweight or obese people (60.3%), 21 and NT had the lowest proportion of older people (7.2%). This increase was observed for both sexes, all ages (except 5-14 years) and in every Australian state and territory.…”

“…Identifying the reasons for this increase were beyond the scope of this study and warrant further investigation; however, likely factors may include an ageing and increasingly obese population, 20,21 symptom control, 3 greater detection of diaphragmatic hernias (incidental or expected) and the widespread uptake of laparoscopic approach, which has radically changed the peri-operative care and recovery. 26 In 2016, TAS had the highest prevalence (67.7%) 21 of overweight or obese people, and the highest proportion of older people (19%), 20 whereas WA had the lowest prevalence of overweight or obese people (60.3%), 21 and NT had the lowest proportion of older people (7.2%). 20 If PEH procedures were principally driven by age and weight, then we would expect TAS to have the highest procedure rates, and WA and NT to have the lowest.…”

Complications and relapses after alloplasty of large and giant hernia of the esophageal aperture of the diaphragm

“…В исследовании Latzko и соавт. на 94 пациентах, с послеоперационным наблюдением в среднем через 23 мес, частота анатомических рецидивов была 21,0%, а реоперации были выполнены пяти больным [30]. В исследовании Ward и соавт.…”