Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair

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.