Laparoscopic management of giant paraesophageal herniation

Background. Many surgeons have found laparoscopic fundoplication effective management of medically recalcitrant gastroesophageal reflux disease (GERD) associated with sliding type I hiatal hernias. The anatomic distortion and technical difficulty inherent with repair has limited the use of laparosco py far repair of "giant" paraesophageal hernias (gPH). Methods. Since July 1993, we have accomplished laparoscopic repair of parae sophageal hiatal hernias in 54 of 60 (90%) patients. Five patients had clas sic type II hernias with total intrathoracic stomachs, and 53 patients had large sliding/paraesophageal type III herniation. Two patients had true par ahiatal hernias. None had gastric incarceration. Median age was 53 years an d 28 of 60 (47%) were women. Chest pain and dysphagia were primary complain ts from 39 of 60 (65%). Heartburn with or without regurgitation was present in 52 of 60 (85%). Preoperative manometry and prolonged pH testing were ob tained an 43 of 60 (72%) and 44 of 60 (73%) patients, respectively. Princip les of repair included reduction of the hernia, excision of the sac, crural approximation, and fundoplication over a 54F bougie (Nissen, 41; Dor, 1; T oupet, 18) to "pexy" the stomach within the abdomen and to control postoper ative reflux. Results. Mean operative time was 202 +/- 81 minutes. Conversion to "open" r epair was required in 6 patients (iatrogenic esophageal injury in 2 patient s and difficult hernia sac dissection in 4 patients). One postoperative mor tality occurred as a result of sepsis and multiorgan failure after an intra operative esophageal perforation. Follow-up barium swallow performed in 44 of 60 patients demonstrated recurrent hiatal hernias in 3 patients. Preoper ative symptoms have been relieved in all but 3 patients. Reoperation for re current paraesophageal herniation has been required in these latter 3 patie nts. Conclusions. Although technically challenging, laparoscopic repair of parae sophageal hiatal hernias is a viable alternative to "open" surgical approac hes. Control of the herniation and the patient's symptoms are equivalent an d hospitalization and return to full activity are shorter. (C) 2001 by The Society of Thoracic Surgeons.