title: Importance of dissection of the hernial sac in laparoscopic surgery for large hiatal hernias.
abstract: OBJECTIVE
  Laparoscopic repair of large hiatal hernia is an appropriate management strategy.
  
  
  METHODS
  A prospective patient series.
  
  
  METHODS
  A university teaching hospital.
  
  
  METHODS
  All patients with hiatal hernias 10 cm or greater in diameter repaired laparoscopically between February 1, 1992, and September 30, 1998.
  
  
  METHODS
  Two operative strategies were used for laparoscopic repair: the first, which was used until early 1996, entailed initial esophageal dissection while leaving the sac in the mediastinum. The second involved preliminary dissection of the hernial sac from the mediastinum before dissecting the esophagus.
  
  
  METHODS
  Successful completion of the procedure using a laparoscopic technique, postoperative complication rate, reoperation rate, and clinical outcome.
  
  
  RESULTS
  Eighty-six patients with a large hiatal hernia underwent attempted repair using laparoscopic methods. The median age was 63 years (range, 30-91 years), and 45 patients (52%) were women. There were 30 sliding, 10 rolling, and 46 mixed hiatal hernias. Operating times ranged from 48 to 240 minutes (median, 90 minutes), and 20 procedures (23%) were converted to an open operation. Conversion was significantly more common in the first half of our experience (16 [40%] of 40 patients vs 4 [9%] of 46 patients) before the operative strategy was changed. Esophageal-lengthening procedures were not carried out for any patient. At follow-up of a median of 2 years, 1 patient has moderate dysphagia, 4 patients have reflux symptoms, and 1 patient has undergone further surgery for a recurrent paraesophageal hernia. An overall satisfactory outcome was achieved in 81 patients (94%).
  
  
  CONCLUSIONS
  Large hiatal hernias can be treated effectively laparoscopically. Dissecting the sac fully from the mediastinum before dissecting the esophagus helps to safely mobilize the esophagus, and we think changing to this strategy is the main reason for the improved laparoscopic success rate reported in the latter half of this series.
authors.affiliation: Department of Surgery, University of Adelaide and The Royal Adelaide Hospital, South Australia, Australia.
authors.forename: D I
authors.initials: DI
authors.lastname: Watson
authors.forename: N
authors.initials: N
authors.lastname: Davies
authors.forename: P G
authors.initials: PG
authors.lastname: Devitt
authors.forename: G G
authors.initials: GG
authors.lastname: Jamieson
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006551:Hernia, Hiatal / Q000473:pathology / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies