Laparoscopic treatment of large paraesophageal hernias

“…Surgery is the only available curative treatment for symptomatic large hiatal hernias (type II–IV). Surgical repair consists of dissection of the hernia sac from the posterior mediastinum, reduction of the herniated intra‐abdominal organs with a tension‐free intra‐abdominal position of the distal esophagus, and posterior cruroplasty [1, 2]. The surgical strategy, however, has not been fully clarified, and controversies such as the appropriate use of antireflux procedures to treat or prevent gastroesophageal reflux disease still persist [3].…”

Section: Introductionmentioning

confidence: 99%

Tailored or Routine Addition of an Antireflux Fundoplication in Laparoscopic Large Hiatal Hernia Repair: A Comparative Cohort Study

et al. 2010

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BackgroundThere 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.MethodsBetween 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.ResultsAn 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.ConclusionsIn 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.

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“…Optimal repair of the paraoesophageal hernia dictates that the hernia sac should be dissected and then preferably excised so as to reduce hernia and symptom recurrence [12,13].…”

Section: Editorialmentioning

confidence: 99%

Paraoesophageal Hernias: A Surgical Perspective

Farhangmehr¹,

Liakakos²,

Àlex³

et al. 2017

J Gastrointest Dig Syst

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EditorialHiatal hernias refer to the condition where intra-abdominal structures herniate into the mediastinum through the oesophageal hiatus. They occur in about 10% of the population. Hiatal hernias are classified in 4 types. Type I or sliding hernia represents 85%-90% of all hiatal hernias. It results from laxity and loss of coherence of the phreno-oesophageal membrane. The gastro-oesophageal junction (GOJ) is displaced above the diaphragm while the fundus remains below the GOJ. Hiatal hernias type II, III and IV or collectively known as paraesophageal hernias represent about 10%-15% of hiatal hernias. Type II hernia results from a localized defect in the phrenooesophageal membrane. The gastric fundus herniates into the mediastinum, while the GOJ remains fixed to the preaortic fascia and the median arcuate ligament. Type III paraoesophageal hernias have elements of both types I and II and have both the GOJ and the fundus herniating through the hiatus. Type IV hiatus hernia is associated with a large defect in the diaphragm defined by the presence of organs other than the stomach in the hernia sac commonly being the transverse colon, spleen, pancreas or small bowel.Paraoesophageal hernia is a condition mainly seen in the elderly population. In most large series, presentation with a median age of 65 to 75 years appears to be the rule [1]. Risk factors for developing hiatal hernia include age greater than 50, BMI>25 and male gender [2]. About 50% of cases are asymptomatic and the hernia is an incidental finding on imaging or endoscopy. In sliding hernias reflux symptoms such as heartburn and regurgitation are more frequent; whilst in paraoesophagheal hernias common symptoms include epigastric or substernal pain, postprandial fullness, dysphagia, nausea, vomiting and dyspnoea. Microcytic anaemia can be present secondary to erosions of the gastric mucosa. Acute symptoms due to gastric outlet obstruction/ gastric volvulus, uncontrolled bleeding, strangulation, perforation, and respiratory compromise are indications for urgent surgery.Hiatus hernia can be an incidental finding on a chest X-ray where the gastric bubble can be seen in the chest. On barium swallow the presence of more than 2 cm separation between the B ring (level of squamocolumnar junction) and the diaphragm suggests a sliding hiatus hernia. If a B ring is not evident on barium swallow (absent in 85% of individuals), the demonstration of at least three rugal folds traversing the diaphragm is diagnostic of a sliding hiatus hernia [3]. In paraoesophageal hernias there is evidence of the fundus herniating into the mediastinum. On endoscopy a sliding hernia is defined as a greater than 2 cm distance between the squamocolumnar junction and the diaphragmatic impression on the stomach [3]. In paraoesophageal hernias the hernia can be visualised on retroflexion (J manoeuvre) of the endoscope that reveals a portion of the stomach, herniating upward through the diaphragm, adjacent to the endoscope [3]. Another indirect indicator of paraoesophageal hernia that sh...

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Laparoscopic treatment of large paraesophageal hernias

Abstract: Laparoscopic treatment of large paraesophageal hernias is feasible. Because recurrences may occur after successful laparoscopic treatment, both resection of the sac and some form of gastropexy are imperative.

Cited by 47 publications

References 27 publications

Preliminary Study of Hiatal Hernia Repair Using Polyglycolic Acid: Trimethylene Carbonate Mesh

Preliminary Study of Hiatal Hernia Repair Using Polyglycolic Acid: Trimethylene Carbonate Mesh

Tailored or Routine Addition of an Antireflux Fundoplication in Laparoscopic Large Hiatal Hernia Repair: A Comparative Cohort Study

Paraoesophageal Hernias: A Surgical Perspective

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