Background: Unlike sliding hiatal hernias, paraesophageal hiatal hernias (P
EH) present a risk of catastrophic complications and should be repaired. To
assess laparoscopic repair of PEH, we prospectively evaluated the outcome
of 38 consecutive patients with type II (20 patients) or III (18 patients)
PEH treated laparoscopically.
Methods: With the use of 5 or 6 ports, laparoscopic PEH reduction and repai
r was attempted. One patient (3%) was converted to an open procedure. In th
e first 12 patients, the hiatus was closed using varying techniques includi
ng the placement of prothestic mesh in 6 patients, and the hernia sac was n
ot routinely excised. In the next 25 patients, the hernia sac always was ex
cised and the hiatus routinely sutured posteriorly to the esophagus. Twenty
-nine patients also underwent either a Nissen (n = 27) or Toupet (n = 2) fu
ndoplication, which is now performed routinely. Sutured anterior gastropexy
was performed selectively in 10 of the first 20 patients, then routinely,
using T-fasteners in the last 17 patients. Barium swallow studies were perf
ormed on all patients at 3 to 5 months postoperatively.
Results: Mean +/- standard error of the mean (SEM) age was 67 +/- 2 year (r
ange, 39-92 years; 11 men, 27 women), and the American Society of Anesthesi
a (ASA) score was 2.5 +/- 0.1. The operating time was 195 +/- 10 min: 244 /- 15 min in the first 12 patients and 170 +/- 11 min in the last 25 patien
ts (p < 0.001). There were three (8%) intraoperation complications, which w
ere treated without sequelae, and four (11%) grade II postoperation morbidi
ties. Median discharge was 3 days, and return to full activity was 14 days.
Two patients (5%) died of cardiovascular disease after discharge. Barium s
wallow revealed 2/35 (6%) PEH recurrences (1 reoperated), 3 (9%) intrathora
cic wraps, and 3 (9%) small sliding hiatal hernias. At follow-up of 1 year
or more, 6/28 (21%) patients noted mild symptoms of reflux or bloating, but
only 1 patient (4%) required medication for these symptoms.
Conclusions: Laparoscopic PEH repair offers a reasonable alternative to tra
ditional surgery, especially for high-risk patients. Rapid recovery is achi
eved with acceptable morbidity and early outcome. Barium x-rays revealed hi
atal abnormalities in a significant fraction of patients, many of whom were
asymptomatic. Longer follow-up will be required to determine the ideal str
ategy for management of these patients.