title: Symptomatic diaphragmatic herniation following open and minimally invasive oesophagectomy: experience from a UK specialist unit.
abstract: BACKGROUND
  The uptake of minimally invasive oesophagectomy (MIO) in the UK has increased dramatically in recent years. Post-oesophagectomy diaphragmatic hernias (PODHs) are rare, but may be influenced by the type of approach to resection. The aim of this study was to compare the incidence of symptomatic PODH following open and MIO in a UK specialist centre.
  
  
  METHODS
  Consecutive patients undergoing oesophagectomy for malignant disease between 1996 and 2012 were included. A standardised, radical approach to the abdominal phase was employed, irrespective of the type of procedure undertaken. Patient demographics, details of surgery and post-operative complications were collected from patient records and a prospective database.
  
  
  RESULTS
  A total of 273 oesophagectomies were performed (205 open; 68 MIO). There were 62 hybrid MIOs (laparoscopic abdomen and thoracotomy) and six total MIOs. Seven patients required conversion and were analysed as part of the open cohort. Nine patients (13.2 %) developed a PODH in the MIO cohort compared with two patients (1.0 %) in the open cohort, (p < 0.001). Five patients developed hernias in the early post-operative period (days 2-10): all following MIO. Both PODHs in the open cohort occurred following transhiatal oesophagectomy. All PODHs were symptomatic and required surgical repair. CT thorax confirmed the diagnosis in 10 patients. Seven hernias were repaired laparoscopically, including two cases in the early post-operative period. PODHs were repaired using the following techniques: suture (n = 6), mesh reinforcement (n = 4) and omentopexy to the anterior abdominal wall without hiatal closure (n = 1). There were two recurrences (18 %).
  
  
  CONCLUSIONS
  The incidence of symptomatic PODH may be higher following MIO compared to open surgery. The reasons for this are unclear and may not be completely explained by the reduction in adhesion formation. Strategies such as fixation of the conduit to the diaphragm and omentopexy to the abdominal wall may reduce the incidence of herniation.
authors.affiliation: Department of General Surgery, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK, davemess@doctors.org.uk.
authors.forename: David E
authors.initials: DE
authors.lastname: Messenger
authors.forename: Simon M
authors.initials: SM
authors.lastname: Higgs
authors.forename: Simon J
authors.initials: SJ
authors.lastname: Dwerryhouse
authors.forename: David F
authors.initials: DF
authors.lastname: Hewin
authors.forename: Mark N
authors.initials: MN
authors.lastname: Vipond
authors.forename: Hugh
authors.initials: H
authors.lastname: Barr
authors.forename: Martin S
authors.initials: MS
authors.lastname: Wadley
mesh_terms: D000368:Aged; D004938:Esophageal Neoplasms / Q000601:surgery; D016629:Esophagectomy / Q000009:adverse effects* / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006548:Hernia, Diaphragmatic / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology*; D006801:Humans; D015994:Incidence; D010535:Laparoscopy / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D013908:Thoracotomy / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed; D006113:United Kingdom / Q000453:epidemiology