Operating on Recurring Paraesophageal Hernia

Shani Belgrave-Heath, MD; Mark R. Wendling, MD; Hector A. Rodriguez-Garcia, MD; Brant K. Oelschlager, MD

Disclosures

February 26, 2016

Operative Technique

We place the patient in a split-leg position. Abdominal access is gained with a Veress needle and optical trocar in the left upper quadrant.

We then place three 5-mm ports in a standard formation for a foregut operation and use a liver retractor in the epigastrium to retract the left lateral segment of the liver after adhesiolysis. The adhesions from the stomach to the crura and mediastinum are taken down until the stomach is reduced into the abdomen. Hernia sac, if encountered, is dissected and excised.

Before reapproximating the crura, we mobilize the esophagus to ensure an adequate amount of intra-abdominal esophageal length. A lighted bougie is used to facilitate undoing the prior fundoplication, which must be undone completely. We then close the hiatal defect posteriorly.

In the current case, we left the previously placed biological mesh in situ. We also placed an anterior suture to avoid angulating the esophagus.

Next, we mark the posterior fundus and bring it around the esophagus. Correct geometry of the fundoplication is crucial in preventing a symptomatic recurrence. A common mistake is creating too loose a fundoplication that then allows for redundant stomach posterior to the esophagus, which may then herniate and cause significant symptoms.

In this case, we did find that redundant stomach had herniated into the hiatus. After bringing the posterior and anterior fundus around the bougie, we use four sutures to create a 2.5-cm fundoplication. We then place a coronal suture on both the right and left side of our fundoplication, anchoring it to the esophagus and diaphragm. We then place posterior gastropexy sutures from the stomach to the diaphragm.

Upper endoscopy is routinely performed to check for injury to the esophagus or stomach. We also evaluate for bleeding and angulation of the esophagus, as well as evaluate the integrity of the wrap.

The patient tolerated the procedure well and was discharged on postoperative day 1.

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Mesh

Mesh material has been widely used for reinforcement of the hiatal closure in the hopes of decreasing recurrence rates. Risk for esophageal erosion and fibrosis leading to progressive dysphagia is a major concern when using mesh at the hiatus.[13] This is primarily a risk of synthetic mesh, and has led many to use biological mesh instead. Although biological mesh appears to be safe, its effectiveness and durability remain incompletely understood.

Recently, a multicenter, prospective, randomized trial involving 108 patients was done to study the use of biological mesh in laparoscopic paraesophageal hernia repair. Patients were randomly assigned to undergo repair with or without onlay crural reinforcement with the biological graft, placed in a keyhole fashion. Patients were followed for 6 months. There was a significant decrease in recurrence rates (9% for the mesh group vs 24% for the nonmesh group). Recurrence was determined radiographically on upper gastrointestinal series.

There were no mesh-related complications. In addition, the patients had no difference in symptom severity scores, in particular for dysphagia, which previously had been shown to be an issue in the short term with placement of prosthetic mesh.

Despite these initial findings, 5 years after the repair, radiologically determined anatomical recurrence was observed to be similar between mesh-treated patients and those treated with primary closure.[10]

Our current institutional practice is to use mesh selectively when the closure is particularly difficult or under tension.

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