Laparoscopic paraesophageal hernia repair.
BACKGROUND
Paraesophageal hernias require surgery to avoid potentially serious complications.


OBJECTIVE
To evaluate paraesophageal hernia repair using the laparoscopic approach.


METHODS
Case series.


METHODS
University hospital and foregut testing laboratory.


METHODS
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.


METHODS
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 re-operation was required in 3 patients: slipped Nissen; small-bowel obstruction due to trocar-site hernia; and organo-axial 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, 1 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.
Perdikis
G
G
Department of Surgery, Mayo Clinic, Jacksonville, Fla, USA.
Hinder
R A
RA
Filipi
C J
CJ
Walenz
T
T
McBride
P J
PJ
Smith
S L
SL
Katada
N
N
Klingler
P J
PJ
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005500:Follow-Up Studies; D006551:Hernia, Hiatal / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D011300:Preoperative Care; D011859:Radiography