Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases

Objective To summarize the authors' laparoscopic experience for paraesophag eal hernia (PEH). Summary Background Data Laparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accoun ts for approximately 5% of all hiatal hernias. Medical management may be as sociated with a 50% progression of symptoms and a significant death rate. C onventional open surgery has a low death rate, but complications are signif icant and return to routine activities is delayed in this frequently elderl y population. Recently, short-term out come studies have reported that mini mally invasive approaches to PEH may be associated with a lower complicatio n rate, a shorter hospital stay, and faster recovery. Methods From July 1995 to February 2000, 100 patients (median age 68) under went laparoscopic repair of a giant PEH. Follow-up included heartburn score s and quality of life measurements using the SF-12 physical component and m ental component summary scores. Results There were 8 type II hernias, 85 type III, and 7 type IV. Sac remov al, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-relat ed death at 5 months from a perioperative stroke. Intraoperative complicati ons included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complica tions included stroke, myocardial infarction, pulmonary emboli, adult respi ratory distress syndrome, and repeat operations (two for abscess and one ea ch for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pum p inhibitors in 10 patients and one repeat operation for recurrence. The me an heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respecti vely (normal, 50). Conclusion This report represents the largest series to date of laparoscopi c repair of giant PEH. In the authors' center with extensive experience in minimally invasive surgery, laparoscopic repair of giant PEH was successful ly performed in 97% of patients, with a minimal complication rate, a 2-day length of stay, and good intermediate results.