Laparoscopic repair of large paraesophageal hiatal hernia

Background. The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias. Methods. Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or t ype III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function , operative techniques, postoperative symptomatology, and complications wer e analyzed. Results. Laparoscopic hernia repair and Nissen fundoplication. was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 t o 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax: in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obs truction in 1. Two patients died within 30 days (5.4%), 1 from delayed sple nic bleeding and I from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven pa tients (87.1%) were improved. Four patients (12.9%) required early postoper ative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 pati ents (12.9%). Functional results were classified as excellent in 17 patient s (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%). Conclusions. Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality . More experience, longer follow-up, and further refinement of the operativ e technique is indicated before it can be recommended as the standard appro ach. (C) 2001 by The Society of Thoracic Surgeons.