LAPAROSCOPIC PARAESOPHAGEAL HERNIA REPAIR

Background: Paraesophageal hernias require surgery to avoid potentiall y serious complications. Objective: To evaluate paraesophageal hernia repair using the laparoscopic approach. Design: Case series. Setting: University hospital and foregut testing laboratory. Subjects: Sixty-fi ve consecutive patients (mean age, 63.6 years; range, 26-90 years). Pr eoperative evaluation included barium esophagogram, endoscopy, esophag eal manometry, and 24-hour pH monitoring. Outcome measures: Operative complications, postoperative morbidity, follow-up symptoms (53 patient s; mean, 18 months; range, 2-54 months) and barium esophagogram (46 pa tients). Results: Fifty-six patients (86%) had a type III hernia and 9 (14%) had a type II hernia. Twenty (65%) of 31 patients who underwent pH monitoring had a positive 24-hour pH score, and 24 (56%) of 43 pat ients who underwent manometry had an incompetent lower esophageal sphi ncter. Four patients had a gastric volvulus and 21 patients had more t han 50% of their stomach in the chest. All patients underwent hernia r eduction, crural repair, and fundoplication (64 Nissen procedures and 1 Toupet procedure). The average duration of surgery was 2 hours. Ther e were 2 conversions: gastric perforation and a difficult dissection b ecause of a large fibrotic sac. Other complications, all managed intra operatively, were 2 gastric perforations and bleeding in 6 patients. A verage length of hospital stay was 2 days (range, 1-23 days). Early re operation was required in 3 patients: slipped Nissen; small-bowel obst ruction due to trocar-site hernia; and organo-axial rotation with gast roduodenal obstruction. Four patients required esophageal dilatation a fter surgery. Forty-nine of 53 patients available for long-term follow -up were satisfied with the results of surgery. Time to full recovery was 3 weeks (range, 1 week to 2 months). Seven of 46 patients experien ced small type I hernias observed on routine follow-up esophagograms. Conclusions: Most paraesophageal hernias are type III. A concomitant a ntireflux procedure is recommended. Paraesophageal hernias can be mana ged successfully by the laparoscopic route with good outcome.