June 1997

Laparoscopic Paraesophageal Hernia Repair

Author Affiliations

From the Department of Surgery, Mayo Clinic, Jacksonville, Fla (Drs Hinder, Smith, and Klingler); and the Department of Surgery, Creighton University School of Medicine, Omaha, Neb (Drs Perdikis, Filipi, Walenz, McBride, and Katada).

Arch Surg. 1997;132(6):586-590. doi:10.1001/archsurg.1997.01430300028005

Background:  Paraesophageal hernias require surgery to avoid potentially serious complications.

Objective:  To evaluate paraesophageal hernia repair using the laparoscopic approach.

Design:  Case series.

Setting:  University hospital and foregut testing laboratory.

Subjects:  Sixty-five consecutive patients (mean age, 63.6 years; range, 26-90 years). Preoperative evaluation included barium esophagogram, endoscopy, esophageal manometry, and 24-hour pH monitoring.

Outcome Measures:  Operative complications, postoperative morbidity, follow-up symptoms (53 patients; mean, 18 months; range, 2-54 months) and barium esophagogram (46 patients).

Results:  Fifty-six patients (86%) had a type III hernia and 9 (14%) had a type II hernia. Twenty (65%) of 31 patients who underwent pH monitoring had a positive 24-hour pH score, and 24 (56%) of 43 patients who underwent manometry had an incompetent lower esophageal sphincter. Four patients had a gastric volvulus and 21 patients had more than 50% of their stomach in the chest. All patients underwent hernia reduction, crural repair, and fundoplication (64 Nissen procedures and 1 Toupet procedure). The average duration of surgery was 2 hours. There were 2 conversions: gastric perforation and a difficult dissection because of a large fibrotic sac. Other complications, all managed intraoperatively, were 2 gastric perforations and bleeding in 6 patients. Average length of hospital stay was 2 days (range, 1-23 days). Early reoperation was required in 3 patients: slipped Nissen; smallbowel obstruction due to trocar-site hernia; and organoaxial rotation with gastroduodenal obstruction. Four patients required esophageal dilatation after surgery. Forty-nine of 53 patients available for long-term follow-up were satisfied with the results of surgery. Time to full recovery was 3 weeks (range, I week to 2 months). Seven of 46 patients experienced small type I hernias observed on routine follow-up esophagograms.

Conclusions:  Most paraesophageal hernias are type III. A concomitant antireflux procedure is recommended. Paraesophageal hernias can be managed successfully by the laparoscopic route with good outcome.Arch Surg. 1997;132:586-590