Laparoscopic repair of large paraesophageal hernia is associated with a low incidence of recurrence and reoperation.
BACKGROUND
Laparoscopic repair of paraesophageal hernia (LRPEH) is a feasible and effective technique. There have been some recent concerns regarding possible high recurrence rates following laparoscopic repair.


METHODS
We reviewed our experience with LRPEH from 5/1996 to 8/2002. Large paraesophageal hernia (PEH) was defined by the presence of more than one-third of the stomach in the thoracic cavity. Principles of repair included reduction of the hernia, excision of the sac, approximation of the crura, and fundoplication. Pre- and postoperative symptoms were evaluated utilizing visual analogue scores (VAS) on a scale ranging from 0 to 10. Patients were followed with VAS and barium esophagram studies. Statistical analysis was performed using two-tailed Student's t-test.


RESULTS
A total of 166 patients with a mean age of 68 years underwent LRPEH. PEH were type II ( n = 43), type III ( n = 104), and type IV ( n = 19). Mean operative time was 160 min. Fundoplications were Nissen (127), Toupet (23), Dor (1), and Nissen-Collis (1). Fourteen patients underwent a gastropexy. One patient required early reoperation to repair an esophageal leak. Mean hospital stay was 3.9 days. At 24 months postoperatively there was statistically significant improvement in the mean symptom scores: heartburn from 6.8 to 0.5, regurgitation from 5.9 to 0.3, dysphagia from 4.0 to 0.5, chest pain from 3.7 to 0.3. Radiographic surveillance was obtained in 120 patients (72%) at a mean of 15 months postoperatively. Six patients (5%) had radiographic evidence of a recurrent paraesophageal hernia (two required surgery), 24 patients (20%) had a sliding hernia (two required surgery), and four patients (3.3%) had wrap failure (all four required surgery). Reoperation was required in 10 patients (6%); two for symptomatic recurrent PEH (1.2%), four for recurrent reflux symptoms (2.4%), and four for dysphagia (2.4%). Patients with abnormal postoperative barium esophagram studies who did not require reoperation have remained asymptomatic at a mean follow up of 14 months.


CONCLUSIONS
LPEHR is a safe and effective treatment for PEH. Postoperative radiographic abnormalities, such as a small sliding hernia, are often seen. The clinical importance of these findings is questionable, since only a small percentage of patients require reoperation. True PEH recurrences are uncommon and frequently asymptomatic.
Andujar
J J
JJ
Minimally Invasive Surgical Program, West Penn Allegheny Health System, 4800 Friendship Ave., Pittsburgh, PA 15224, USA.
Papasavas
P K
PK
Birdas
T
T
Robke
J
J
Raftopoulos
Y
Y
Gagné
D J
DJ
Caushaj
P F
PF
Landreneau
R J
RJ
Keenan
R J
RJ
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001464:Barium; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology; D003287:Contrast Media; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods* / Q000706:statistics & numerical data; D005764:Gastroesophageal Reflux / Q000453:epidemiology / Q000209:etiology; D006551:Hernia, Hiatal / Q000150:complications / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D015994:Incidence; D010535:Laparoscopy / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D010414:Pennsylvania; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011859:Radiography; D012008:Recurrence; D012086:Reoperation / Q000706:statistics & numerical data; D012189:Retrospective Studies
D003287:Contrast Media; D001464:Barium