LAPAROSCOPIC REPAIR OF PARAESOPHAGEAL HIATAL-HERNIAS

Background: Regardless of symptoms, paraesophageal hiatal hernias shou ld be repaired in order to prevent complications. This study reports t he University of California San Francisco experience with laparoscopic repair of paraesophageal hiatal hernias, emphasizing the technical st eps essential for good results. Patients and Methods: From May 1993 to September 1997, 55 patients, 27 women and 28 men, with a mean age of 67 years (range, 35-102 years) underwent laparoscopic repair of paraes ophageal hernias at the University of California San Francisco. Sympto ms, which had been present an average of 85 months before surgery, con sisted mainly of pain (55%), heartburn (52%), dysphagia (45%), and reg urgitation (41%). Of the four patients who presented with acute illnes s, two had gastric obstruction, one had severe dyspnea, and one had ga stric bleeding. Endoscopy demonstrated esophagitis in 25 (69%) of 36 p atients, and 24-hour pH-monitoring demonstrated acid reflux in 22 (67% ) of 33 patients. Manometry detected severely impaired distal esophage al peristalsis in 17 (52%) of 33 patients. The preferred operation con sisted of reduction of the hernia, excision of the sack and the gastri c fat pad, closure of the enlarged hiatus without mesh, and constructi on of a fundoplication anchored by sutures within the abdomen. Results : Of the 55 patients, the operations of 49 were completed laparoscopic ally using the following reconstructions: Guarner (270-degree) fundopl ication (30 patients); Nissen fundoplication (10 patients); and gastro pexy (9 patients). Five (9%) operations were converted to laparotomies . The average operating time was 219 minutes; the average blood loss w as less than 25 mL; resumption of an unrestricted diet, 27 hours; and mean hospital stay, 58 hours. Intraoperative technical complications o ccurred in five (9%) patients. One patient died during surgery from a sudden pulmonary embolus. Two (4%) patients required a second operatio n for recurrent paraesophageal hernias. Conclusions: Laparoscopic repa ir of paraesophageal hiatal hernias is safe and effective, but the ope ration is difficult and good results hinge on details of the operative technique and the surgeon's experience. In this series, the crus coul d always be closed securely without using mesh. We realized early that a fundoplication should be a routine step, because it corrects reflux and is the best method to secure the gastroesophageal junction in the abdomen. (C) 1998 by the American College of Surgeons.