Laparoscopic Paraesophageal Hernia Repair

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Abstract
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