Paraesophageal Hernia Repair

Abstract

Paraesophageal hiatal hernia (PHH), accounting for only 5% of all hiatal hernias, may result in potentially life threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the gastric mucosa. It is traditionally believed that PHH is an indication for surgery. The repair of paraesophageal hernia is technically challenging and controversial. The purpose of this article is to overview the current status of indication of surgery; operative techniques including hernia sac resection, esophageal lengthening procedure, crural repair, and additional antireflux procedure. Results: All symptomatic patients should be surgically treated, when operation is possible. It seems reasonable that asymptomatic or minimally symptomatic patients do not necessarily require surgery and that a more selective approach should be used. The penetration rate is not high, laparoscopic approach is currently the standard care. The hernia sac should be excised and resected circumferentially. Collis-Nissen procedure continues to be the method of choice also in the laparoscopic era, when lengthening procedure of the shortened esophagus is in consideration. Although symptomatic recurrence after suture closure of the crura is uncommon, primary repair is associated with a high rate of anatomic recurrence. Prosthetic mesh repair is reportedly associated with a recurrence rate as low as 5%, at the price of rare but serious complications such as erosion and fibrosis. Although scientific proof is lacking, fundoplication is the most common procedure to be added after crural repair.

Large Paraesophageal Hiatus Hernia: Is Surgery Mandatory?

“…It has to be noted though that the vast majority of these patients are in their 70s or 80s, with high prevalence of comorbidities and pose increased operative risk. On the other hand, large HH repair led to significant quality of life improvement on symptomatic patients regardless of age in previously published studies (17). The surgical approach of choice is laparoscopic surgery, with all the benefits of minimally invasive surgery, and thus an enhanced recovery postoperative course.…”

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

“…It requires respective gastroplasty in rare cases, most commonly with the Collis method [11]. Although this method is considered an effective technique of esophageal elongation, there are some reports of dysfunction of the anti-reflux barrier resulting from this procedure, mostly due to impaired self-clearance of the distal newly formed esophageal segment [12].…”

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“…Surgical repair of these defects is recommended upon their diagnosis, as they can lead to bowel strangulation, incarceration, necrosis, and perforation. 4 Surgical principles of tension-free repair should be followed, and synthetic materials (eg, polytetrafluoroethylene and polypropylene) have been used successfully for this. 2 The transplanted population, however, deserves special attention with reduction of potential long-term infectious complications.…”