- Email: [email protected]
Laparoscopic Repair of Large Hiatal Hernia Without the Need for Esophageal Lengthening With Low Morbidity and Rare Symptomatic Recurrence
Accepted Manuscript Title: Laparoscopic Repair of Large Hiatal Hernia Without the Need for Esophageal Lengthening, with Low Morbidity and Rare Symptomatic Recurrence Author: Farzaneh Banki, Chandni Kaushik, David Roife, Kyle G. Mitchell, Charles C. Miller III PII: DOI: Reference:
S1043-0679(17)30157-0 http://dx.doi.org/doi: 10.1053/j.semtcvs.2017.05.011 YSTCS 980
To appear in:
Seminars in Thoracic and Cardiovascular Surgery
Please cite this article as: Farzaneh Banki, Chandni Kaushik, David Roife, Kyle G. Mitchell, Charles C. Miller III, Laparoscopic Repair of Large Hiatal Hernia Without the Need for Esophageal Lengthening, with Low Morbidity and Rare Symptomatic Recurrence, Seminars in Thoracic and Cardiovascular Surgery (2017), http://dx.doi.org/doi: 10.1053/j.semtcvs.2017.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 2 3
Laparoscopic Repair of Large Hiatal Hernia without the Need for Esophageal Lengthening, with Low Morbidity and Rare Symptomatic Recurrence
4 1,2
1
1
1
5
Farzaneh Banki, MD ; Chandni Kaushik, MS ; David Roife, MD ; Kyle G. Mitchell, MD ;
6 7
Charles C. Miller III, PhD
8 9 10
1
1
McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth) 2 Memorial Hermann Southeast Esophageal Disease Center
11 12
Corresponding author:
13
Farzaneh Banki, MD
14
Associate Professor, Department of Surgery
15
McGovern Medical School at UTHealth
16
Director of Esophageal Disease Center, Memorial Hermann Southeast
17
11800 Astoria Blvd.
18
Houston, Texas 77089
19
Tel: 713.486.1100
20
Email: [email protected]
21 22
Key words: Large hiatal hernia; laparoscopic approach; esophageal lengthening
23 24
The authors have no disclosures or conflicts of interest to report. In addition, no
25
outside funding of any kind was provided.
26 1 Page 1 of 30
27
Glossary of Abbreviations
28 29
BMI = Body mass index
30
GERD= Gastroesophageal reflux disease
31
IQR = Interquartile range
32
PEG = Percutaneous endoscopic gastrostomy
33
POD = Postoperative day
34
PPI = Proton pump inhibitors
35 36
2 Page 2 of 30
37
Abstract:
38
Objective: To assess the symptomatic recurrence in patients who underwent
39
laparoscopic repair of large hiatal hernias without esophageal lengthening procedure.
40 41
Methods: Patients who underwent laparoscopic repair of large hiatal hernia from
42
9/2009-9/2015 by a single surgeon were identified in the retrospective review. The
43
patients were followed prospectively by the operating surgeon, using a structured
44
questionnaire, administered by telephone to assess for symptomatic recurrence.
45
Symptomatic recurrence was defined as requirement for a reoperative procedure for
46
symptomatic recurrent hiatal hernia.
47 48
Results: There were 215 laparoscopic repairs. Reoperations (n=35) and type I hernias
49
<4 cm (n=49) were excluded. The study population included 131 patients: 36 had type I,
50
4 type II, 37 type III, and 54 type IV hernias. There were102 females/29 males, age 63
51
(56-74). For repair, 102 Toupet, 28 Nissen, and 1 Dor fundoplication were performed.
52
The duration of operation was 138 (119-172) minutes. Adequate esophageal length was
53
obtained by mediastinal esophageal mobilization in all, without Collis gastroplasty. Mesh
54
was used in 106. There was 1 conversion and 2 delayed esophageal leaks. The length
55
of stay was 2 (1-3) days. Perioperative complications included atrial fibrillation in 5,
56
gastric distension/ileus in 5, reintubation in 3, heparin-induced thrombocytopenia in 1,
57
and temporary dialysis in 1. There was no 30-day or in-hospital mortality. The
58
questionnaire was completed in 99/131 (76%) at 24 (9-38) months: 85/99 (86%) were
59
free of preoperative symptoms; 91/99 (92%) were satisfied with the operation; and
3 Page 3 of 30
60
73/99 (74%) were off proton pump inhibitors. Reoperation for symptomatic recurrent
61
hiatal hernia occurred in 8/99 (8%), 2 in the perioperative period and 6 at 25 (8-31)
62
months.
63 64
Conclusions: Laparoscopic repair of large hiatal hernia can be performed with low
65
morbidity and result in excellent patient satisfaction. Tension-free, intra-abdominal
66
esophageal length can be achieved laparoscopically without Collis gastroplasty.
67
Reoperation for symptomatic recurrence is rare.
68 69 70
Central Message: Tension-free, intra-abdominal esophageal length can be achieved
71
laparoscopically with mediastinal esophageal mobilization from the aorta, pleura and the spine
72
in patients with large hiatal hernia.
73
Perspective STatement: Our report describes adequate, intra-abdominal esophageal length by
74
esophageal mediastinal mobilization without the need for Collis gastroplasty, which is used in
75
40- 53% of specialized thoracic esophageal centers. In our study, the most common type of
76
hiatal hernia was type IV, presenting in 54/131 (41%) patients. Out of 131, 102 (78%) were
77
treated with a Toupet fundoplication.
4 Page 4 of 30
78 79
Central Image: Laparoscopic view of esophageal mediastinal mobilization from the
80
aorta and spine.
81 82 83
5 Page 5 of 30
84
Introduction
85
Laparoscopic repair of large hiatal hernia is technically challenging. The rate of
86
radiographic recurrence following laparoscopic repair of giant paraesophageal hiatal
87
hernia in specialized centers is reported to be 12-16%, with the use of Collis
88
gastroplasty in 40 to 53%.
89
asymptomatic and reoperation for symptomatic recurrence can occur in 3.2-11.0% of
90
cases.
91
1,2
The majority of patients with radiographic recurrence are
2,3
The aim of this study was to assess the symptomatic outcomes of patients who
92
underwent laparoscopic repair of large hiatal hernias with esophageal mediastinal
93
mobilization and without the need for an esophageal lengthening procedure in a single,
94
specialized esophageal center by a single surgeon and one surgical team.
95 96
Material and Methods
97
We retrospectively reviewed the results of laparoscopic repair of large hiatal hernia at
98
the McGovern Medical School at UTHealth, Esophageal Disease Center at Memorial
99
Hermann Southeast, in Houston, Texas, from 09/16/2009 to 09/08/2015. The patients
100
were followed prospectively by the operating surgeon using a structured questionnaire,
101
administered by telephone, to assess for symptomatic recurrence. Symptomatic
102
recurrence was defined as requirement for a reoperative procedure for symptomatic
103
recurrent hiatal hernia. The study was approved by the institutional board review at
104
UTHealth and Memorial Hermann Southeast Hospital and consents were obtained from
105
the patients.
106
We excluded reoperative procedures and type I hernias <4 cm. All patients with
6 Page 6 of 30
107
type I hiatal hernia ≥4 cm and type II-IV hiatal hernias who underwent a first-time
108
operation were included in the study. All the procedures were performed by one
109
surgeon with the same surgical/anesthesia team, and the same operating room staff.
110
The postoperative care was provided by a trained team of thoracic nurses.
111
Nissen fundoplication was performed in patients with main symptoms of
112
heartburn and regurgitation, with positive pH or with esophagitis and/or Barrett’s
113
esophagus, with adequate esophageal clearance on esophagram and with more than
114
70% peristaltic esophageal contractions with amplitude of contractions within normal
115
limits on high resolution manometry. Toupet fundoplication was performed in patients
116
with the main symptoms of dysphagia, chest pain, shortness of breath and melena
117
(mostly symptoms caused by intrathoracic migration of the stomach and its mechanical
118
consequences, rather than GERD), with large hiatal hernia or any evidence of
119
dysmotility on esophagram or with less than 70% peristaltic esophageal contractions, or
120
low amplitude of contractions on high resolution manometry.
121
Over the years, we have changed our practice and we now perform Toupet
122
fundoplication for all patients with large hiatal hernia. This change was as the result of
123
the age of the population with large hiatal hernia, which is associated with some degree
124
of esophageal dysmotility, to prevent the side effect of dysphagia associated with
125
Nissen fundoplication and to preserve the ability to burp and vomit with Toupet
126
fundoplication. Other reasons included no need to place a bougie to construct a Toupet
127
fundoplication, which will prevent the risk of esophageal perforation after extensive
128
mediastinal mobilization and comparable relief of symptoms with both types of
7 Page 7 of 30
129
fundoplications. In addition, we have changed our practice in this series and used
130
Tisseel to keep the mesh in place for crural closure reinforcement.
131 132 133
Dor fundoplication was used in a patient with achalasia and a large hiatal hernia who underwent a Heller myotomy and repair of hiatal hernia. A nasogastric tube was placed postoperatively only in patients with abdominal
134
distension on physical exam and on imaging studies. The patients were started on a
135
clear liquid diet in the post-anesthesia recovery room and were discharged on full liquid
136
diet. Videoesophagram was obtained on POD 1 in patients with type IV hiatal hernia,
137
who had the entire stomach in the chest, to assure esophageal clearance and adequate
138
anatomic position of the stomach.
139
The operating surgeon called each patient to follow up using a questionnaire to
140
assess symptoms. The questionnaire was designed based on symptoms of
141
gastroesophageal reflux disease, relief of symptoms following surgery, new onset of
142
symptoms based on known side effects of antireflux procedure, the ability to eat and
143
perform activity after surgery, and overall patient satisfaction, as we previously
144
reported.
4
145 146
Statistical Analysis
147
Frequency data were analyzed by contingency table methods. The null hypothesis was
148
rejected at a nominal alpha of p<0.05. All computations were performed using SAS
149
software version 9.4 (SAS Institute, Inc., Cary, NC). Values are presented as median
150
and interquartile range (IQR).
8 Page 8 of 30
151 152 153 154
Reoperation-free survival was defined as freedom from re-operation or death, estimated by the product-limit method of Kaplan and Meier. Esophageal stenting and dilations were evaluated as recurrent events using Nelson-Aalen cumulative hazard.
155 156
Preoperative Clinical Evaluation
157
The preoperative evaluation included a detailed history and physical exam. A
158
videoesophagram was obtained in all patients by a specialized gastrointestinal
159
radiologist. The size of the hiatal hernia was measured on the videoesophagram in the
160
prone oblique position. An upper endoscopy was obtained in all patients. High-
161
resolution manometry was obtained in patients with moderate-to-severe dysmotility to
162
solids or liquids on videoesophagram. Prolonged esophageal pH monitoring using a
163
wireless capsule sensor (Bravo®, Given Imaging, Yokneam, Israel) for 48 hours was
164
obtained in patients with type I hiatal hernia whose main symptoms were heartburn and
165
regurgitation.
166 167
Operative Technique
168
The procedure is performed with the patient in the lithotomy position and in the reverse
169
Trendelenburg position. The surgeon stands between the patient’s legs. One subxiphoid
170
port for liver retractor and 4 working ports are placed.
171
In many patients with the type IV hernia, the stomach is partially reduced into the
172
abdomen in the lithotomy position and the hernia seems slightly smaller in the
173
laparoscopic view compared to the videoesophagram. An example of a type IV hiatal
9 Page 9 of 30
174
hernia with the entire stomach herniated into the chest on a videoesophagram and the
175
laparoscopic view in the lithotomy position is shown in Figure 1.
176
In patients with type IV hiatal hernia, there is significant incarcerated omentum
177
that needs to be reduced into the abdomen prior to reduction of herniated stomach. An
178
example of a type IV hiatal hernia with herniated omentum and small bowel on a
179
videoesophagram and the laparoscopic view with herniated omentum, prior to reduction
180
of stomach and small bowel, is shown in Figure 2.
181
The hernia sac, as seen in the Figure 3, is fully excised.
182
The short gastric vessels are divided using Harmonic scalpel. The esophagus is
183
mobilized from the pleura, aorta, and the spine up to the level of the pericardium, as
184
seen in Figure 3, and in the central image, to obtain at least 2 cm, tension-free, intra-
185
abdominal esophageal length, as seen in Figure 4. An upper endoscopy is performed
186
to assure absence of esophageal or gastric perforation.
187
The peritoneal lining of the crura is preserved as much as possible to increase
188
the strength of crural closure. The splenic attachments to the left crus are divided to
189
prevent tension at the time of closure. Crural closure is performed using interrupted #0
190
Ethibond stitches in a figure-of-8 manner using a Tie-Knot® device (LSI Solutions,
191
Victor, New Jersey) to approximate the right and left crus without strangulation, which
192
may result in weakness of closure and future herniation. The crural closure continues up
193
to the level of the diaphragmatic crura with careful attention not to strangulate the
194
esophagus, which may result in postoperative dysphagia. To prevent a tight crural
195
closure, a laparoscopic 10 mm Babcock should pass medial to the right crus and get
10 Page 10 of 30
196
into the mediastinum without resistance and an upper endoscopy should allow easy
197
access into the stomach.
198
Toupet fundoplication is performed by placing 3 stitches on each side between
199
the esophageal wall and the stomach using 2-0 silk stitches and a Tie-Knot device, as
200
seen in Figure 4.
201
Nissen fundoplication is performed after a 60 F Bougie is inserted inside the
202
esophagus. One Pledgeted U-stitch 2-0 Prolene is used to construct the fundoplication.
203
Two 2-0 silk stitches are placed, 1 above and 1 below the U stitch to complete the
204
fundoplication.
205
Dor fundoplication was used in a patient with achalasia and type IV hiatal hernia
206
by placing interrupted 2-0 silk stitches between the fundus of the stomach, the crus and
207
edges of the myotomy.
208
At the completion of the procedure, an upper endoscopy is performed to assure
209
easy entrance to the stomach, to assess for leak and to visualize the fundoplication in
210
the retroflexed view, as seen in Figure 4. In the majority of patients with type III and
211
type IV hiatal hernia, the right crus is atretic, therefore the crural closure is reinforced
212
with a tailored piece of Vicryl mesh, as seen in Figure 4. The Vicryl mesh is maintained
213
in place using Tisseel (Baxter, Deerfield, Illinois) or Evicel® (Ethicon, Somerville, New
214
Jersey), which is placed over the mesh. No mesh is used if the right and left crus are of
215
good caliber and tension-free crural closure can be achieved.
216 217 218
The accompanying video shows a laparoscopic repair of a type III and large type IV hiatal hernia. One patient with two recurrent hiatal hernias required gastric preserving Roux-
11 Page 11 of 30
219
en-Y esophagojejunostomy, which was performed after mediastinal esophageal
220
mobilization was done and adequate intra-abdominal esophageal length was achieved.
221
The esophagus was divided right above the gastroesophageal junction. The
222
anastomosis was performed between the distal esophagus and the jejunum in an end
223
(esophagus) to side (jejunum) fashion. A temporary gastrostomy tube was placed in the
224
stomach, which was then removed.
225 226
Results
227
From 09/16/2009 to 09/08/2015, a total of 215 laparoscopic hernia repairs were
228
performed. We excluded reoperative procedures (n=35) and type I hernias <4cm
229
(n=49). A total of 131 patients were included in the study. There were 102/131 (78%)
230
females and 29/131 (22%) males, with a median age of 63 (56-74) years, and body
231
mass index (BMI) of 29.8 (26.5-33.5) kg/m.2 The type of hiatal hernias is shown in Table
232
I.
233
The 7 most common preoperative primary symptoms (the chief complaint) and
234
the overall preoperative symptoms are shown in Table 2.
235
Esophagitis was seen in 21/131 (16%) and Barrett’s esophagus in 16/131 (12%): 5/16
236
had long segment Barrett’s esophagus and Schatzki’s ring in 6/131 (4.5%). None had
237
stricture.
238
A 2-cm, tension-free, intra-abdominal esophageal length was obtained in all
239
patients, without the need for an esophageal lengthening procedure. Vicryl absorbable
240
mesh, with Tisseel or Evicel for reinforcement of crural closure, was used in 106/131
241
(81%) patients. The fundoplications included 102/131 (77.8%) Toupet, 28/131 (21.3%) 12 Page 12 of 30
242
Nissen and 1/131 (0.8%) Dor (in a patient who had a type IV hiatal hernia and
243
achalasia).
244
There was 1 conversion in case #6 of the series as the result of esophageal
245
perforation during bougie insertion, which was treated with laparotomy and primary
246
repair. Delayed esophageal leak occurred in 2/131 (1.5%) patients who had undergone
247
Toupet fundoplication, 1 on POD 7, in a patient with type III hiatal hernia, and 1 on POD
248
18, in a patient with type IV hiatal hernia. Both were treated with drainage and an
249
esophageal stent, which resolved both leaks. Each developed stricture, requiring stents
250
and dilations. One required self-dilation at home and was then able to eat as desired
251
and was asymptomatic at the time of questionnaire. The other was able to eat as
252
desired, but at the time of questionnaire, had died of heart failure. There were no leaks
253
in the last 70 repairs.
254 255 256
The operative data, perioperative complications and postoperative course are shown in Table 3. In-patient complications included reintubation in 3/131 (0.2%) patients, 2/3
257
occurred as the result of aspiration pneumonia. One patient with aspiration pneumonia
258
needed a tracheostomy, and percutaneous endoscopic gastrostomy (PEG). Gastric
259
distension or ileus requiring a nasogastric tube occurred in 5/131 (3.8%): 1/5 of whom
260
required a PEG for treating gastric bloating. Heparin-induced thrombocytopenia
261
occurred in 1 patient, which resulted in embolic stroke and aortic embolus requiring
262
embolectomy. One patient had a laparoscopic reoperation on POD1 for retrieval of a
263
retained Penrose ring, which was placed around the gastroesophageal junction for
13 Page 13 of 30
264
retraction. A nasogastric tube was placed in 5/131 (3.8%) postoperatively as the result
265
of abdominal distension.
266
Complications after discharge included laparoscopic repair of port site hernia (the
267
left flank port) in 1/131 (0.8%) patients, esophageal dilation in 7/131(5.3%) and
268
esophageal stent in 1/131(0.8%) for treatment of tight fundoplication.
269
A follow-up, symptomatic questionnaire via phone was obtained by the operating
270
surgeon in 99/131 (76%) of patients at 24 months (9-38). The results are shown in
271
Table 4.
272
At the time of follow-up questionnaire, there were 7 deaths, with the median age
273
of 76.3 years (61-88), at the median of 16 months (7-29) from the time of surgery, 6
274
were non-related death, including: syncope in 1; myocardial infarction in 2; lung cancer
275
in 1; and heart failure in 2. There was 1 related death in a patient who had undergone
276
repair of type III hiatal hernia and had aspiration pneumonia, requiring tracheostomy
277
and PEG, who died 63 days after surgery from head trauma following a fall in a nursing
278
facility. All 7 had undergone a Toupet fundoplication. At the median follow-up time of 24
279
months, reoperation-free survival rate was 97% in Toupet and 90% in Nissen (p<0.19).
280
See Figure 5.
281
There was no difference between heartburn [5/77 (7%) vs. 2/22 (9%), p<0.68],
282
regurgitation [8/77 (10%) vs. 3/22 (14%), p<0.67], dysphagia [9/77 (12%) vs. 3/22
283
(14%), p<0.81], gas bloating [22/77 (29%) vs. 4/22 (18%), p<0.33] and diarrhea [10/77
284
(13%) vs. 5/22 (23%), p<0.27] between the Toupet and Nissen groups at the time of
285
follow-up questionnaire. The number of patients who were on PPI at the time of
14 Page 14 of 30
286
questionnaire was less in the Toupet compared to Nissen group [16/77 (21%) vs. 10/22
287
(46%), p<0.0204].
288
Reoperation for symptomatic recurrent hiatal hernia occurred in 8/99 (8%) of
289
patients. The initial type of hiatal hernias included type I (size 4-7 cm) in 5, and type IV
290
in 3 (2/3 had the entire stomach in the chest). Vicryl mesh for reinforcement of crural
291
was used in 5/8 at the initial operation. Of the 8 reoperations, 2 were performed during
292
the same admission: 1 after acute gastric distention, resulting in reherniation and
293
obstruction, and 1 following severe retching and reherniation. The remaining 6/8 were
294
performed at the median of 25 months (8-31). Of the 8 recurrences, 5 were repaired
295
laparoscopically, 1 was started laparoscopically, but was converted to laparotomy, and
296
2 were performed via laparotomy. One patient with intrathoracic stomach, who
297
underwent reoperative laparoscopic recurrent hiatal repair, presented with a recurrent
298
hernia and required gastric preserving Roux-en-Y esophagojejunostomy.
299 300 301
At the time of the symptomatic follow-up questionnaire via phone, none of the patients had undergone a reoperation at another institution. At the median follow-up time of 24 months, the recurrent event rate for
302
esophageal dilation or stent was 12% in the Toupet and 20% in the Nissen groups
303
(p=0.22).
304 305
Discussion
306
Our study confirms that repair of large hiatal hernias, including type III and type IV, can
307
be performed laparoscopically with low morbidity, excellent patient satisfaction and low
308
symptomatic recurrence. Further, the results of our study show that tension-free, intra-
15 Page 15 of 30
309
abdominal esophageal length can be achieved laparoscopically with esophageal
310
mediastinal mobilization and without the need for an esophageal lengthening procedure
311
in patients with large hiatal hernias.
312
Collis gastroplasty has been reported in 40-56%
1,5
of primary laparoscopic giant 6
313
paraesophageal hiatal hernia repairs and 43% in reoperative laparoscopic repairs. The
314
use of an esophageal lengthening procedure may be subjective and driven by the
315
training and institutional tradition. In a review of 662 patients over a decade, the use of
316
Collis gastroplasty was shown to have decreased from 86% to 53%.
317
2
We achieved at least 2 cm, tension-free, intra-abdominal esophageal length in all
318
patients by esophageal mediastinal mobilization and without the need for Collis
319
gastroplasty. Despite devascularization of the distal third of the esophagus, there was
320
no visible necrosis of the mucosa seen endoscopically or discoloration of the
321
esophageal muscular layer seen laparoscopically at the end of the procedure. Of the
322
131 patients, 129 (98%) were free of leak or esophageal necrosis. Delayed esophageal
323
leak occurred on POD7 and POD18 in 2 patients who had undergone a Toupet
324
fundoplication. In both, after 3 stitches had been placed at each side between the
325
esophageal wall and gastric fundus, 2 extra cephalad stitches were placed between the
326
esophagus and the fundus to achieve better anatomical configuration of the
327
fundoplication. In both patients, the extra cephalad stitches may have created extra
328
tension between the esophageal wall and the gastric fundus, possibly resulting in the
329
delayed distal esophageal perforation on the top of the fundoplication. Our theory is
330
supported by the fact that, in both patients, the perforation, as seen on the endoscopy,
331
was in the distal esophagus, just above the Toupet fundoplication. And, since we have 16 Page 16 of 30
332
adopted the new practice of not placing further cephalad stitches after the Toupet
333
fundoplication is completed, there have been no further esophageal leaks in the last 70
334
repairs in the series—and in all further Toupet fundoplications to date. We believe that
335
the esophagus can be fully mobilized and the direct aortic branches to the distal
336
esophagus can be divided up to the level of the pericardium, without esophageal
337
necrosis or ischemia.
338
Esophageal stricture, regarded as the most common predictor of esophageal 7
339
shortening, was not seen in any of the patients in our study. Absence of stricture and
340
low rate of Barrett’s esophagus and esophagitis in our series may be contributing
341
factors, allowing achievement of adequate, tension-free, intra-abdominal esophageal
342
length without the need for Collis gastroplasty. The use of PPI for medical management
343
of peptic stricture and esophagitis may have changed the surgical management of hiatal
344
hernia repair and antireflux surgery, allowing adequate intra-abdominal esophageal
345
length without the need for Collis gastroplasty.
346
The rate of conversion in laparoscopic primary repair of giant paraesophageal 5,8
347
hiatal hernia in specialized centers is reported to be 0.8%-1.5%.
348
conversion as the result of intraoperative perforation of the posterior wall of the distal
349
esophagus by a bougie, in a patient with intrathoracic stomach with the plan for a
350
Nissen fundoplication. The procedure was converted to laparotomy and the perforation
351
was primarily repaired and buttressed with Nissen fundoplication.
352
We had one
The most common pattern of failure of fundoplication requiring reoperation is 6,9-11
353
known to be herniation of the wrap.
In our previous report of 50 reoperative
354
antireflux procedures in 47 patients, 38/47 (81%) of whom were referred to our center,
4
17 Page 17 of 30
355
the most common pattern of failure was herniation of the fundoplication in 45/50 (90%).
356
An important component for prevention of herniation, in addition to adequate intra-
357
abdominal length, is a tension-free crural closure. The crura should easily approximate
358
to avoid muscular tearing and also to prevent strangulation of the muscle, which may
359
lead to necrosis. Careful attention should be given to preserve the peritoneum overlying
360
the right and left crus and divide the splenic attachments to the left crus, as described
361
previously, to prevent tension during the crural closure.
362
12
The use of mesh has been shown to reduce the rate of recurrent hiatal 13,14
363
hernias.
A multi-center, randomized trial showed a reduction in recurrence of hiatal
364
hernia after primary laparoscopic paraesophageal hernia repair at 6 months with the
365
use of biologic prosthetic mesh (9%) compared to primary closure (24%). However,
366
follow up at 58 months showed no difference between the 2 groups, with 54%
367
radiological recurrence in the group who had biologic prosthetic mesh vs. 59% in the
368
group who had primary crural closure.
15
16
369
We used mesh for reinforcement of the crural closure in the majority of our
370
patients with large hiatal hernias. Longer follow up will be required to identify the rate of
371
recurrence with the use of mesh in our series.
372
There was no difference between heartburn, regurgitation and dysphagia
373
between the Nissen and Toupet groups at the time of follow-up questionnaire. The
374
number of patients who were on PPI at the time of questionnaire was less in the Toupet
375
compared to Nissen group. This result depicts that Toupet fundoplication provides
376
similar symptom control compared to Nissen.
18 Page 18 of 30
377
Overall, it seems that with the advances in laparoscopic surgery and refinement
378
of laparoscopic techniques, more large hiatal hernias, including type III and complex
379
type IV, will be repaired laparoscopically. The combination of hernia sac excision,
380
achievement of tension-free, intra-abdominal esophageal length with mediastinal
381
esophageal mobilization, adequate crural closure and reinforcement with mesh, if
382
required, results in good outcomes, high patient satisfaction and rare symptomatic
383
recurrence in patients with large hiatal hernias.
384
It is important to mention that the low morbidity, short length of stay and high
385
patient satisfaction in our series is largely the result of assembling a dedicated thoracic
386
team, including a trained and consistent operating room staff and educated thoracic
387
nurses, who provide specialized postoperative care to our patients, as we previously
388
reported.
17
389 390
Conclusion
391
Laparoscopic repair of large hiatal hernias can be performed with low morbidity,
392
excellent patient satisfaction and rare symptomatic recurrence. Tension-free, intra-
393
abdominal esophageal length can be achieved laparoscopically with esophageal
394
mediastinal mobilization and without the need for esophageal lengthening procedure.
395
The use of PPI for medical management of peptic strictures, a known predictor of
396
shortened esophagus, may have changed the practice of hiatal hernia repair and
397
antireflux surgery. Therefore, the esophageal lengthening procedure with Collis
398
gastroplasty, once an integral part of the surgical management of GERD and hiatal
399
hernia, may become the procedure of the past.
19 Page 19 of 30
400 401
Acknowledgements
402
We would like to acknowledge Dr. Munish Chawla for performing and interpreting the
403
radiographic images for the patients in this study.
404 405
Limitations
406
We acknowledge the limitations of the study, which include a low number of patients
407
and short duration of follow up. In addition, patients may have underrepresented their
408
symptoms or potential dissatisfactions to the operating surgeon, who obtained the
409
questionnaires. The number of recurrent hiatal hernias may also be underestimated
410
since follow-up radiographic studies were not obtained in all patients.
20 Page 20 of 30
411 412
References: 1. Zehetner J, Demeester SR, Ayazi S, Kilday P, Augustin F, Hagen JA, et
413
al.Laparoscopic versus open repair of paraesophageal hernia: the second
414
decade. J Am Coll Surg. 2011 May;212(5): 813-820.
415
2. Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ, et
416
al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair.
417
J Thorac Cardiovasc Surg. 2010 Feb;139(2): 395-404.
418
3. RathoreMA,Andrabi, SI, Bhatti MI, Jajfi SM, McMurray, A. Metaanalysis of
419
Recurrence AfterLaparoscopic Repair of Paraesophageal Hernia.JSLS. 2007
420
Oct-Dec; 11(4): 456-460.
421
4. Banki F, Kaushik C, Roife D, Chawla M, Casimir R, Miller C III. Laparoscopic
422
Redo Antireflux Surgery: A Safe Procedure with High Patient Satisfaction and
423
Low Morbidity.Am J Surg. 2016 (in press).
424
5. Pierre AF, Luketich JD, Fernando HC, Christie NA, Buenaventura PO, Litle VR,
425
et al. Results of laparoscopic repair of giant paraesophageal hernias: 200
426
consecutive patients. Ann Thorac Surg. 2002 Dec;74(6): 1909-1915; discussion
427
1915-6.
428
6. Awais O,Luketich JD, Schuchert MJ, Morse CR, Wilson J, Gooding WE,et
429
al.Reoperative antireflux surgery for failed fundoplication: an analysis of
430
outcomes in 275 patients.Ann Thorac Surg. 2011 Sep;92(3): 1083-1089;
431
discussion 1089-1090.
21 Page 21 of 30
432
7. GastalOL, Hagen JA, Peters JH, Campos GM, Hashemi M, Theisen J, et al.
433
Short esophagus: analysis of predictors and clinical implications.Arch Surg. 1999
434
Jun;134(6): 633-636; discussion 637-638.
435
8. DiazS, Brunt ML, Klingensmith ME, Frisella PM, Soper NJ.Laparoscopic
436
paraesophageal hernia repair, a challenging operation: medium-term outcome of
437
116 patients.J Gastrointest Surg. February 2003, Volume 7(1): 59-67.
438
9. FurneeEJ, Draaisma WA, Broeders IA, Gooszen HG. Surgical reintervention
439
after failed antireflux surgery: a systematic review of the literature.J Gastrointest
440
Surg. 2009 Aug;13(8): 1539-1549.
441
10. Ohnmacht GA, Deschamps C, Cassivi SD, Nichols FS, Allen MS, Schleck CD, et
442
al.Failed Antireflux Surgery: Results After Reoperation.Ann Thorac Surg. 2006;
443
81:2050-2054.
444 445 446
11. vanBeekDB, Auyang ED, Soper NJ. A comprehensive review of laparoscopic redo fundoplication. Surg Endosc. 2011 Mar;25(3): 706-712. 12. Nason, KS, Levy RM, Witteman, BP, Luketich JD.The Laparoscopic Approach to
447
Paraesophageal Hernia Repair.J Gastrointest Surg. 2012 Feb; 16(2): 417-426.
448
13. Granderath FA, Schweiger UM, Kamolz T, Asche KU, Pointner R.Laparoscopic
449
Nissen fundoplication with prosthetic hiatal closure reduces postoperative
450
intrathoracic wrap herniation: preliminary results of a prospective randomized
451
functional and clinical study.Arch Surg. 2005 Jan;140(1):40-48.
452
14. Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective,
453
randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs.
454
simple cruroplasty for large hiatal hernia. Arch Surg. 2002 Jun;137(6):649-52.
22 Page 22 of 30
455
15. Oelschlager BK, Pellegrini CA, Hunter JG, Soper NJ, Brunt ML, Sheppard BC, et
456
al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal
457
hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006
458
Oct;244(4): 481-490.
459
16. Oelschlager BK, Pellegrini CA, Hunter JG, Brunt ML, Soper NJ, Sheppard BC, et
460
al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal
461
hernia repair: long-term follow-up from a multicenter, prospective, randomized
462
trial.J Am Coll Surg. 2011 Oct;213(4): 461-468.
463
17. Banki F, Ochoa K, Carrillo ME, Leake SS, Estrera AL, Kahlil K, Safi HJ. A
464
surgical team with focus on staff education in a community hospital improves
465
outcomes, costs and patient satisfaction. Am J Surg. 2013 Dec;206(6):1007-14.
466
23 Page 23 of 30
467
FIGURE LEGEND
468
Figure1. A: Type IV hiatal hernia on videoesophagram. S=Stomach; L=Left lung;
469
SB=Small bowel. B: Laparoscopic view of a type IV hiatal hernia. D=Duodenum;
470
PPV=Prepyloric vein; S=Stomach; RC=Right crus; LC=Left crus.
471 472
Figure 2. A: Type IV hiatal hernia with intrathoracic stomach and herniated small bowel
473
on videoesophagram. S=Stomach with organoaxial volvulus; L=Left lung; SB=Small
474
bowel. B: Laparoscopic view of a type IV hiatal hernia. S=Stomach 100% herniated into
475
the chest cavity; RC=Right crus; LC=Left crus.
476 477
Figure 3. A: Laparoscopic view showing excision of the hernia sac in a patient with type
478
IV hiatal hernia. B: Laparoscopic view of the esophagus after excision of the hernia sac
479
and esophageal mediastinal mobilization in a patient with type IV hiatal hernia.
480
RC=Right crus; S=Spine; E=Esophagus; LP=left pleura.
481 482
Figure 4. A: 2 cm, tension-free, intra-abdominal esophageal length following
483
mediastinal esophageal mobilization without the need for esophageal lengthening in a
484
patient with a type IV hiatal hernia. C=Crural closure; P=Penrose placed around the
485
gastroesophageal junction for retraction; E=Esophagus. B: Laparoscopic view of a
486
Toupet fundoplication (T) placed around a 3 cm, tension-free, intra-abdominal
487
esophagus, following repair of a type IV hiatal hernia. C: Retroflexed endoscopic view of
488
a Toupet fundoplication (T). D: Laparoscopic view of Vicryl mesh placed over the crural
489
closure in a patient with Nissen fundoplication after repair of a type III hiatal hernia. The
24 Page 24 of 30
490
Nissen fundoplication is retracted to the left to expose the mesh. V=Vicryl mesh over the
491
crural closure; RC=Right crus; E=Esophagus; N=Nissen fundoplication.
492 493
Figure 5. This chart shows that at the median follow-up time of 24 months, reoperation-
494
free survival rate was 97% in Toupet and 90% in Nissen (p<0.19).
495 496
25 Page 25 of 30
497
Table 1. Type of hiatal hernia (n=131) Hiatal Hernia Type
N (%)
IV
54 (41.2%) (26 with 100% herniated stomach)
III
37 (28.2%)
I ( ≥ 4 cm) 5 cm (4-5.25)
36 (27.5%)
II 6 cm (5-8)
4 (3.1%)
498 499 500
26 Page 26 of 30
501
Table 2. The 7 most common preoperative primary symptoms (the chief complaint) and
502
the overall preoperative symptoms. Preoperative primary symptom (chief complaint) Dysphagia Heartburn Epigastric pain Regurgitation Chest pain/pressure Anemia Shortness of breath Preoperative overall symptoms Regurgitation Dysphagia Heartburn Epigastric pain Nocturnal cough/choking sensation Chest pain/pressure Anemia Shortness of breath Pneumonia
n ( %) 32 (24%) 30 (23%) 20 (15%) 18 (14%) 16 (12%) 6 (5%) 3 (2%) n ( %) 99 (76%) 88 (67%) 88 (67%) 65 (50%) 52 (40%) 42 (32%) 33 (25%) 21 (16%) 17 (13%)
503 504 505 506 507
27 Page 27 of 30
508
Table 3. Operative data, perioperative complications and postoperative course. Operative time (min) 138 (119-172) Complications
n
Atrial fibrillation
5
Gastric distention or ileus requiring nasogastric tube
5
Blood transfusion
4
Reintubation ( 2/3 had aspiration pneumonia)
3
Delayed esophageal leak
2
Conversion for esophageal perforation by bougie
1
Heparin-induced thrombocytopenia resulting in stroke
1
Temporary dialysis
1
Laparoscopic retrieval of retained Penrose
1
Length of stay (days)
2 (1-3)
30-day or in hospital mortality
none
509 510
28 Page 28 of 30
511
Table 4. Symptomatic questionnaire follow-up via phone obtained in 99/131 (76%)
512
patients at 24 (9-38) months. Questions
N (%)
Free of preoperative symptoms
85/99 (86%)
Satisfied with the operation
91/99 (92%)
Would have undergo the procedure again knowing the current outcome
87/99 (88%)
Could eat as desired
93/99 (94%)
Were able to return to daily activities in less than 2 weeks
74/99 (75%)
Free of typical symptoms of reflux Free of heartburn
92/99 (93%)
Free of regurgitation
88/99 (89%)
Free of dysphagia
87/99 (88%)
Off PPI therapy
73/99 (74%)
Median weight change
0 lbs (-18 to 12)
New onset symptoms Excessive gas
26/99 (26%)
Bloating
19/99 (19%)
Diarrhea
15/99 (15%).
513 514 515
29 Page 29 of 30
516
VIDEO LEGEND
517
Part I: This video demonstrates laparoscopic reduction of type III hiatal hernia,
518
mediastinal esophageal mobilization from the aorta and the pleura, primary crural
519
closure using a Tie-Knot device, Toupet fundoplication, crural closure reinforcement
520
with Vicryl mesh and Evicel to keep the mesh in place. Part II: This video demonstrates
521
laparoscopic mediastinal esophageal mobilization in a patient with a large type IV hiatal
522
hernia, with intrathoracic stomach, herniated omentum and small bowel. A 2-cm,
523
tension-free, intra-abdominal esophageal length is achieved.
524
30 Page 30 of 30
S1043-0679(17)30157-0 http://dx.doi.org/doi: 10.1053/j.semtcvs.2017.05.011 YSTCS 980
To appear in:
Seminars in Thoracic and Cardiovascular Surgery
Please cite this article as: Farzaneh Banki, Chandni Kaushik, David Roife, Kyle G. Mitchell, Charles C. Miller III, Laparoscopic Repair of Large Hiatal Hernia Without the Need for Esophageal Lengthening, with Low Morbidity and Rare Symptomatic Recurrence, Seminars in Thoracic and Cardiovascular Surgery (2017), http://dx.doi.org/doi: 10.1053/j.semtcvs.2017.05.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 2 3
Laparoscopic Repair of Large Hiatal Hernia without the Need for Esophageal Lengthening, with Low Morbidity and Rare Symptomatic Recurrence
4 1,2
1
1
1
5
Farzaneh Banki, MD ; Chandni Kaushik, MS ; David Roife, MD ; Kyle G. Mitchell, MD ;
6 7
Charles C. Miller III, PhD
8 9 10
1
1
McGovern Medical School at the University of Texas Health Science Center at Houston (UTHealth) 2 Memorial Hermann Southeast Esophageal Disease Center
11 12
Corresponding author:
13
Farzaneh Banki, MD
14
Associate Professor, Department of Surgery
15
McGovern Medical School at UTHealth
16
Director of Esophageal Disease Center, Memorial Hermann Southeast
17
11800 Astoria Blvd.
18
Houston, Texas 77089
19
Tel: 713.486.1100
20
Email: [email protected]
21 22
Key words: Large hiatal hernia; laparoscopic approach; esophageal lengthening
23 24
The authors have no disclosures or conflicts of interest to report. In addition, no
25
outside funding of any kind was provided.
26 1 Page 1 of 30
27
Glossary of Abbreviations
28 29
BMI = Body mass index
30
GERD= Gastroesophageal reflux disease
31
IQR = Interquartile range
32
PEG = Percutaneous endoscopic gastrostomy
33
POD = Postoperative day
34
PPI = Proton pump inhibitors
35 36
2 Page 2 of 30
37
Abstract:
38
Objective: To assess the symptomatic recurrence in patients who underwent
39
laparoscopic repair of large hiatal hernias without esophageal lengthening procedure.
40 41
Methods: Patients who underwent laparoscopic repair of large hiatal hernia from
42
9/2009-9/2015 by a single surgeon were identified in the retrospective review. The
43
patients were followed prospectively by the operating surgeon, using a structured
44
questionnaire, administered by telephone to assess for symptomatic recurrence.
45
Symptomatic recurrence was defined as requirement for a reoperative procedure for
46
symptomatic recurrent hiatal hernia.
47 48
Results: There were 215 laparoscopic repairs. Reoperations (n=35) and type I hernias
49
<4 cm (n=49) were excluded. The study population included 131 patients: 36 had type I,
50
4 type II, 37 type III, and 54 type IV hernias. There were102 females/29 males, age 63
51
(56-74). For repair, 102 Toupet, 28 Nissen, and 1 Dor fundoplication were performed.
52
The duration of operation was 138 (119-172) minutes. Adequate esophageal length was
53
obtained by mediastinal esophageal mobilization in all, without Collis gastroplasty. Mesh
54
was used in 106. There was 1 conversion and 2 delayed esophageal leaks. The length
55
of stay was 2 (1-3) days. Perioperative complications included atrial fibrillation in 5,
56
gastric distension/ileus in 5, reintubation in 3, heparin-induced thrombocytopenia in 1,
57
and temporary dialysis in 1. There was no 30-day or in-hospital mortality. The
58
questionnaire was completed in 99/131 (76%) at 24 (9-38) months: 85/99 (86%) were
59
free of preoperative symptoms; 91/99 (92%) were satisfied with the operation; and
3 Page 3 of 30
60
73/99 (74%) were off proton pump inhibitors. Reoperation for symptomatic recurrent
61
hiatal hernia occurred in 8/99 (8%), 2 in the perioperative period and 6 at 25 (8-31)
62
months.
63 64
Conclusions: Laparoscopic repair of large hiatal hernia can be performed with low
65
morbidity and result in excellent patient satisfaction. Tension-free, intra-abdominal
66
esophageal length can be achieved laparoscopically without Collis gastroplasty.
67
Reoperation for symptomatic recurrence is rare.
68 69 70
Central Message: Tension-free, intra-abdominal esophageal length can be achieved
71
laparoscopically with mediastinal esophageal mobilization from the aorta, pleura and the spine
72
in patients with large hiatal hernia.
73
Perspective STatement: Our report describes adequate, intra-abdominal esophageal length by
74
esophageal mediastinal mobilization without the need for Collis gastroplasty, which is used in
75
40- 53% of specialized thoracic esophageal centers. In our study, the most common type of
76
hiatal hernia was type IV, presenting in 54/131 (41%) patients. Out of 131, 102 (78%) were
77
treated with a Toupet fundoplication.
4 Page 4 of 30
78 79
Central Image: Laparoscopic view of esophageal mediastinal mobilization from the
80
aorta and spine.
81 82 83
5 Page 5 of 30
84
Introduction
85
Laparoscopic repair of large hiatal hernia is technically challenging. The rate of
86
radiographic recurrence following laparoscopic repair of giant paraesophageal hiatal
87
hernia in specialized centers is reported to be 12-16%, with the use of Collis
88
gastroplasty in 40 to 53%.
89
asymptomatic and reoperation for symptomatic recurrence can occur in 3.2-11.0% of
90
cases.
91
1,2
The majority of patients with radiographic recurrence are
2,3
The aim of this study was to assess the symptomatic outcomes of patients who
92
underwent laparoscopic repair of large hiatal hernias with esophageal mediastinal
93
mobilization and without the need for an esophageal lengthening procedure in a single,
94
specialized esophageal center by a single surgeon and one surgical team.
95 96
Material and Methods
97
We retrospectively reviewed the results of laparoscopic repair of large hiatal hernia at
98
the McGovern Medical School at UTHealth, Esophageal Disease Center at Memorial
99
Hermann Southeast, in Houston, Texas, from 09/16/2009 to 09/08/2015. The patients
100
were followed prospectively by the operating surgeon using a structured questionnaire,
101
administered by telephone, to assess for symptomatic recurrence. Symptomatic
102
recurrence was defined as requirement for a reoperative procedure for symptomatic
103
recurrent hiatal hernia. The study was approved by the institutional board review at
104
UTHealth and Memorial Hermann Southeast Hospital and consents were obtained from
105
the patients.
106
We excluded reoperative procedures and type I hernias <4 cm. All patients with
6 Page 6 of 30
107
type I hiatal hernia ≥4 cm and type II-IV hiatal hernias who underwent a first-time
108
operation were included in the study. All the procedures were performed by one
109
surgeon with the same surgical/anesthesia team, and the same operating room staff.
110
The postoperative care was provided by a trained team of thoracic nurses.
111
Nissen fundoplication was performed in patients with main symptoms of
112
heartburn and regurgitation, with positive pH or with esophagitis and/or Barrett’s
113
esophagus, with adequate esophageal clearance on esophagram and with more than
114
70% peristaltic esophageal contractions with amplitude of contractions within normal
115
limits on high resolution manometry. Toupet fundoplication was performed in patients
116
with the main symptoms of dysphagia, chest pain, shortness of breath and melena
117
(mostly symptoms caused by intrathoracic migration of the stomach and its mechanical
118
consequences, rather than GERD), with large hiatal hernia or any evidence of
119
dysmotility on esophagram or with less than 70% peristaltic esophageal contractions, or
120
low amplitude of contractions on high resolution manometry.
121
Over the years, we have changed our practice and we now perform Toupet
122
fundoplication for all patients with large hiatal hernia. This change was as the result of
123
the age of the population with large hiatal hernia, which is associated with some degree
124
of esophageal dysmotility, to prevent the side effect of dysphagia associated with
125
Nissen fundoplication and to preserve the ability to burp and vomit with Toupet
126
fundoplication. Other reasons included no need to place a bougie to construct a Toupet
127
fundoplication, which will prevent the risk of esophageal perforation after extensive
128
mediastinal mobilization and comparable relief of symptoms with both types of
7 Page 7 of 30
129
fundoplications. In addition, we have changed our practice in this series and used
130
Tisseel to keep the mesh in place for crural closure reinforcement.
131 132 133
Dor fundoplication was used in a patient with achalasia and a large hiatal hernia who underwent a Heller myotomy and repair of hiatal hernia. A nasogastric tube was placed postoperatively only in patients with abdominal
134
distension on physical exam and on imaging studies. The patients were started on a
135
clear liquid diet in the post-anesthesia recovery room and were discharged on full liquid
136
diet. Videoesophagram was obtained on POD 1 in patients with type IV hiatal hernia,
137
who had the entire stomach in the chest, to assure esophageal clearance and adequate
138
anatomic position of the stomach.
139
The operating surgeon called each patient to follow up using a questionnaire to
140
assess symptoms. The questionnaire was designed based on symptoms of
141
gastroesophageal reflux disease, relief of symptoms following surgery, new onset of
142
symptoms based on known side effects of antireflux procedure, the ability to eat and
143
perform activity after surgery, and overall patient satisfaction, as we previously
144
reported.
4
145 146
Statistical Analysis
147
Frequency data were analyzed by contingency table methods. The null hypothesis was
148
rejected at a nominal alpha of p<0.05. All computations were performed using SAS
149
software version 9.4 (SAS Institute, Inc., Cary, NC). Values are presented as median
150
and interquartile range (IQR).
8 Page 8 of 30
151 152 153 154
Reoperation-free survival was defined as freedom from re-operation or death, estimated by the product-limit method of Kaplan and Meier. Esophageal stenting and dilations were evaluated as recurrent events using Nelson-Aalen cumulative hazard.
155 156
Preoperative Clinical Evaluation
157
The preoperative evaluation included a detailed history and physical exam. A
158
videoesophagram was obtained in all patients by a specialized gastrointestinal
159
radiologist. The size of the hiatal hernia was measured on the videoesophagram in the
160
prone oblique position. An upper endoscopy was obtained in all patients. High-
161
resolution manometry was obtained in patients with moderate-to-severe dysmotility to
162
solids or liquids on videoesophagram. Prolonged esophageal pH monitoring using a
163
wireless capsule sensor (Bravo®, Given Imaging, Yokneam, Israel) for 48 hours was
164
obtained in patients with type I hiatal hernia whose main symptoms were heartburn and
165
regurgitation.
166 167
Operative Technique
168
The procedure is performed with the patient in the lithotomy position and in the reverse
169
Trendelenburg position. The surgeon stands between the patient’s legs. One subxiphoid
170
port for liver retractor and 4 working ports are placed.
171
In many patients with the type IV hernia, the stomach is partially reduced into the
172
abdomen in the lithotomy position and the hernia seems slightly smaller in the
173
laparoscopic view compared to the videoesophagram. An example of a type IV hiatal
9 Page 9 of 30
174
hernia with the entire stomach herniated into the chest on a videoesophagram and the
175
laparoscopic view in the lithotomy position is shown in Figure 1.
176
In patients with type IV hiatal hernia, there is significant incarcerated omentum
177
that needs to be reduced into the abdomen prior to reduction of herniated stomach. An
178
example of a type IV hiatal hernia with herniated omentum and small bowel on a
179
videoesophagram and the laparoscopic view with herniated omentum, prior to reduction
180
of stomach and small bowel, is shown in Figure 2.
181
The hernia sac, as seen in the Figure 3, is fully excised.
182
The short gastric vessels are divided using Harmonic scalpel. The esophagus is
183
mobilized from the pleura, aorta, and the spine up to the level of the pericardium, as
184
seen in Figure 3, and in the central image, to obtain at least 2 cm, tension-free, intra-
185
abdominal esophageal length, as seen in Figure 4. An upper endoscopy is performed
186
to assure absence of esophageal or gastric perforation.
187
The peritoneal lining of the crura is preserved as much as possible to increase
188
the strength of crural closure. The splenic attachments to the left crus are divided to
189
prevent tension at the time of closure. Crural closure is performed using interrupted #0
190
Ethibond stitches in a figure-of-8 manner using a Tie-Knot® device (LSI Solutions,
191
Victor, New Jersey) to approximate the right and left crus without strangulation, which
192
may result in weakness of closure and future herniation. The crural closure continues up
193
to the level of the diaphragmatic crura with careful attention not to strangulate the
194
esophagus, which may result in postoperative dysphagia. To prevent a tight crural
195
closure, a laparoscopic 10 mm Babcock should pass medial to the right crus and get
10 Page 10 of 30
196
into the mediastinum without resistance and an upper endoscopy should allow easy
197
access into the stomach.
198
Toupet fundoplication is performed by placing 3 stitches on each side between
199
the esophageal wall and the stomach using 2-0 silk stitches and a Tie-Knot device, as
200
seen in Figure 4.
201
Nissen fundoplication is performed after a 60 F Bougie is inserted inside the
202
esophagus. One Pledgeted U-stitch 2-0 Prolene is used to construct the fundoplication.
203
Two 2-0 silk stitches are placed, 1 above and 1 below the U stitch to complete the
204
fundoplication.
205
Dor fundoplication was used in a patient with achalasia and type IV hiatal hernia
206
by placing interrupted 2-0 silk stitches between the fundus of the stomach, the crus and
207
edges of the myotomy.
208
At the completion of the procedure, an upper endoscopy is performed to assure
209
easy entrance to the stomach, to assess for leak and to visualize the fundoplication in
210
the retroflexed view, as seen in Figure 4. In the majority of patients with type III and
211
type IV hiatal hernia, the right crus is atretic, therefore the crural closure is reinforced
212
with a tailored piece of Vicryl mesh, as seen in Figure 4. The Vicryl mesh is maintained
213
in place using Tisseel (Baxter, Deerfield, Illinois) or Evicel® (Ethicon, Somerville, New
214
Jersey), which is placed over the mesh. No mesh is used if the right and left crus are of
215
good caliber and tension-free crural closure can be achieved.
216 217 218
The accompanying video shows a laparoscopic repair of a type III and large type IV hiatal hernia. One patient with two recurrent hiatal hernias required gastric preserving Roux-
11 Page 11 of 30
219
en-Y esophagojejunostomy, which was performed after mediastinal esophageal
220
mobilization was done and adequate intra-abdominal esophageal length was achieved.
221
The esophagus was divided right above the gastroesophageal junction. The
222
anastomosis was performed between the distal esophagus and the jejunum in an end
223
(esophagus) to side (jejunum) fashion. A temporary gastrostomy tube was placed in the
224
stomach, which was then removed.
225 226
Results
227
From 09/16/2009 to 09/08/2015, a total of 215 laparoscopic hernia repairs were
228
performed. We excluded reoperative procedures (n=35) and type I hernias <4cm
229
(n=49). A total of 131 patients were included in the study. There were 102/131 (78%)
230
females and 29/131 (22%) males, with a median age of 63 (56-74) years, and body
231
mass index (BMI) of 29.8 (26.5-33.5) kg/m.2 The type of hiatal hernias is shown in Table
232
I.
233
The 7 most common preoperative primary symptoms (the chief complaint) and
234
the overall preoperative symptoms are shown in Table 2.
235
Esophagitis was seen in 21/131 (16%) and Barrett’s esophagus in 16/131 (12%): 5/16
236
had long segment Barrett’s esophagus and Schatzki’s ring in 6/131 (4.5%). None had
237
stricture.
238
A 2-cm, tension-free, intra-abdominal esophageal length was obtained in all
239
patients, without the need for an esophageal lengthening procedure. Vicryl absorbable
240
mesh, with Tisseel or Evicel for reinforcement of crural closure, was used in 106/131
241
(81%) patients. The fundoplications included 102/131 (77.8%) Toupet, 28/131 (21.3%) 12 Page 12 of 30
242
Nissen and 1/131 (0.8%) Dor (in a patient who had a type IV hiatal hernia and
243
achalasia).
244
There was 1 conversion in case #6 of the series as the result of esophageal
245
perforation during bougie insertion, which was treated with laparotomy and primary
246
repair. Delayed esophageal leak occurred in 2/131 (1.5%) patients who had undergone
247
Toupet fundoplication, 1 on POD 7, in a patient with type III hiatal hernia, and 1 on POD
248
18, in a patient with type IV hiatal hernia. Both were treated with drainage and an
249
esophageal stent, which resolved both leaks. Each developed stricture, requiring stents
250
and dilations. One required self-dilation at home and was then able to eat as desired
251
and was asymptomatic at the time of questionnaire. The other was able to eat as
252
desired, but at the time of questionnaire, had died of heart failure. There were no leaks
253
in the last 70 repairs.
254 255 256
The operative data, perioperative complications and postoperative course are shown in Table 3. In-patient complications included reintubation in 3/131 (0.2%) patients, 2/3
257
occurred as the result of aspiration pneumonia. One patient with aspiration pneumonia
258
needed a tracheostomy, and percutaneous endoscopic gastrostomy (PEG). Gastric
259
distension or ileus requiring a nasogastric tube occurred in 5/131 (3.8%): 1/5 of whom
260
required a PEG for treating gastric bloating. Heparin-induced thrombocytopenia
261
occurred in 1 patient, which resulted in embolic stroke and aortic embolus requiring
262
embolectomy. One patient had a laparoscopic reoperation on POD1 for retrieval of a
263
retained Penrose ring, which was placed around the gastroesophageal junction for
13 Page 13 of 30
264
retraction. A nasogastric tube was placed in 5/131 (3.8%) postoperatively as the result
265
of abdominal distension.
266
Complications after discharge included laparoscopic repair of port site hernia (the
267
left flank port) in 1/131 (0.8%) patients, esophageal dilation in 7/131(5.3%) and
268
esophageal stent in 1/131(0.8%) for treatment of tight fundoplication.
269
A follow-up, symptomatic questionnaire via phone was obtained by the operating
270
surgeon in 99/131 (76%) of patients at 24 months (9-38). The results are shown in
271
Table 4.
272
At the time of follow-up questionnaire, there were 7 deaths, with the median age
273
of 76.3 years (61-88), at the median of 16 months (7-29) from the time of surgery, 6
274
were non-related death, including: syncope in 1; myocardial infarction in 2; lung cancer
275
in 1; and heart failure in 2. There was 1 related death in a patient who had undergone
276
repair of type III hiatal hernia and had aspiration pneumonia, requiring tracheostomy
277
and PEG, who died 63 days after surgery from head trauma following a fall in a nursing
278
facility. All 7 had undergone a Toupet fundoplication. At the median follow-up time of 24
279
months, reoperation-free survival rate was 97% in Toupet and 90% in Nissen (p<0.19).
280
See Figure 5.
281
There was no difference between heartburn [5/77 (7%) vs. 2/22 (9%), p<0.68],
282
regurgitation [8/77 (10%) vs. 3/22 (14%), p<0.67], dysphagia [9/77 (12%) vs. 3/22
283
(14%), p<0.81], gas bloating [22/77 (29%) vs. 4/22 (18%), p<0.33] and diarrhea [10/77
284
(13%) vs. 5/22 (23%), p<0.27] between the Toupet and Nissen groups at the time of
285
follow-up questionnaire. The number of patients who were on PPI at the time of
14 Page 14 of 30
286
questionnaire was less in the Toupet compared to Nissen group [16/77 (21%) vs. 10/22
287
(46%), p<0.0204].
288
Reoperation for symptomatic recurrent hiatal hernia occurred in 8/99 (8%) of
289
patients. The initial type of hiatal hernias included type I (size 4-7 cm) in 5, and type IV
290
in 3 (2/3 had the entire stomach in the chest). Vicryl mesh for reinforcement of crural
291
was used in 5/8 at the initial operation. Of the 8 reoperations, 2 were performed during
292
the same admission: 1 after acute gastric distention, resulting in reherniation and
293
obstruction, and 1 following severe retching and reherniation. The remaining 6/8 were
294
performed at the median of 25 months (8-31). Of the 8 recurrences, 5 were repaired
295
laparoscopically, 1 was started laparoscopically, but was converted to laparotomy, and
296
2 were performed via laparotomy. One patient with intrathoracic stomach, who
297
underwent reoperative laparoscopic recurrent hiatal repair, presented with a recurrent
298
hernia and required gastric preserving Roux-en-Y esophagojejunostomy.
299 300 301
At the time of the symptomatic follow-up questionnaire via phone, none of the patients had undergone a reoperation at another institution. At the median follow-up time of 24 months, the recurrent event rate for
302
esophageal dilation or stent was 12% in the Toupet and 20% in the Nissen groups
303
(p=0.22).
304 305
Discussion
306
Our study confirms that repair of large hiatal hernias, including type III and type IV, can
307
be performed laparoscopically with low morbidity, excellent patient satisfaction and low
308
symptomatic recurrence. Further, the results of our study show that tension-free, intra-
15 Page 15 of 30
309
abdominal esophageal length can be achieved laparoscopically with esophageal
310
mediastinal mobilization and without the need for an esophageal lengthening procedure
311
in patients with large hiatal hernias.
312
Collis gastroplasty has been reported in 40-56%
1,5
of primary laparoscopic giant 6
313
paraesophageal hiatal hernia repairs and 43% in reoperative laparoscopic repairs. The
314
use of an esophageal lengthening procedure may be subjective and driven by the
315
training and institutional tradition. In a review of 662 patients over a decade, the use of
316
Collis gastroplasty was shown to have decreased from 86% to 53%.
317
2
We achieved at least 2 cm, tension-free, intra-abdominal esophageal length in all
318
patients by esophageal mediastinal mobilization and without the need for Collis
319
gastroplasty. Despite devascularization of the distal third of the esophagus, there was
320
no visible necrosis of the mucosa seen endoscopically or discoloration of the
321
esophageal muscular layer seen laparoscopically at the end of the procedure. Of the
322
131 patients, 129 (98%) were free of leak or esophageal necrosis. Delayed esophageal
323
leak occurred on POD7 and POD18 in 2 patients who had undergone a Toupet
324
fundoplication. In both, after 3 stitches had been placed at each side between the
325
esophageal wall and gastric fundus, 2 extra cephalad stitches were placed between the
326
esophagus and the fundus to achieve better anatomical configuration of the
327
fundoplication. In both patients, the extra cephalad stitches may have created extra
328
tension between the esophageal wall and the gastric fundus, possibly resulting in the
329
delayed distal esophageal perforation on the top of the fundoplication. Our theory is
330
supported by the fact that, in both patients, the perforation, as seen on the endoscopy,
331
was in the distal esophagus, just above the Toupet fundoplication. And, since we have 16 Page 16 of 30
332
adopted the new practice of not placing further cephalad stitches after the Toupet
333
fundoplication is completed, there have been no further esophageal leaks in the last 70
334
repairs in the series—and in all further Toupet fundoplications to date. We believe that
335
the esophagus can be fully mobilized and the direct aortic branches to the distal
336
esophagus can be divided up to the level of the pericardium, without esophageal
337
necrosis or ischemia.
338
Esophageal stricture, regarded as the most common predictor of esophageal 7
339
shortening, was not seen in any of the patients in our study. Absence of stricture and
340
low rate of Barrett’s esophagus and esophagitis in our series may be contributing
341
factors, allowing achievement of adequate, tension-free, intra-abdominal esophageal
342
length without the need for Collis gastroplasty. The use of PPI for medical management
343
of peptic stricture and esophagitis may have changed the surgical management of hiatal
344
hernia repair and antireflux surgery, allowing adequate intra-abdominal esophageal
345
length without the need for Collis gastroplasty.
346
The rate of conversion in laparoscopic primary repair of giant paraesophageal 5,8
347
hiatal hernia in specialized centers is reported to be 0.8%-1.5%.
348
conversion as the result of intraoperative perforation of the posterior wall of the distal
349
esophagus by a bougie, in a patient with intrathoracic stomach with the plan for a
350
Nissen fundoplication. The procedure was converted to laparotomy and the perforation
351
was primarily repaired and buttressed with Nissen fundoplication.
352
We had one
The most common pattern of failure of fundoplication requiring reoperation is 6,9-11
353
known to be herniation of the wrap.
In our previous report of 50 reoperative
354
antireflux procedures in 47 patients, 38/47 (81%) of whom were referred to our center,
4
17 Page 17 of 30
355
the most common pattern of failure was herniation of the fundoplication in 45/50 (90%).
356
An important component for prevention of herniation, in addition to adequate intra-
357
abdominal length, is a tension-free crural closure. The crura should easily approximate
358
to avoid muscular tearing and also to prevent strangulation of the muscle, which may
359
lead to necrosis. Careful attention should be given to preserve the peritoneum overlying
360
the right and left crus and divide the splenic attachments to the left crus, as described
361
previously, to prevent tension during the crural closure.
362
12
The use of mesh has been shown to reduce the rate of recurrent hiatal 13,14
363
hernias.
A multi-center, randomized trial showed a reduction in recurrence of hiatal
364
hernia after primary laparoscopic paraesophageal hernia repair at 6 months with the
365
use of biologic prosthetic mesh (9%) compared to primary closure (24%). However,
366
follow up at 58 months showed no difference between the 2 groups, with 54%
367
radiological recurrence in the group who had biologic prosthetic mesh vs. 59% in the
368
group who had primary crural closure.
15
16
369
We used mesh for reinforcement of the crural closure in the majority of our
370
patients with large hiatal hernias. Longer follow up will be required to identify the rate of
371
recurrence with the use of mesh in our series.
372
There was no difference between heartburn, regurgitation and dysphagia
373
between the Nissen and Toupet groups at the time of follow-up questionnaire. The
374
number of patients who were on PPI at the time of questionnaire was less in the Toupet
375
compared to Nissen group. This result depicts that Toupet fundoplication provides
376
similar symptom control compared to Nissen.
18 Page 18 of 30
377
Overall, it seems that with the advances in laparoscopic surgery and refinement
378
of laparoscopic techniques, more large hiatal hernias, including type III and complex
379
type IV, will be repaired laparoscopically. The combination of hernia sac excision,
380
achievement of tension-free, intra-abdominal esophageal length with mediastinal
381
esophageal mobilization, adequate crural closure and reinforcement with mesh, if
382
required, results in good outcomes, high patient satisfaction and rare symptomatic
383
recurrence in patients with large hiatal hernias.
384
It is important to mention that the low morbidity, short length of stay and high
385
patient satisfaction in our series is largely the result of assembling a dedicated thoracic
386
team, including a trained and consistent operating room staff and educated thoracic
387
nurses, who provide specialized postoperative care to our patients, as we previously
388
reported.
17
389 390
Conclusion
391
Laparoscopic repair of large hiatal hernias can be performed with low morbidity,
392
excellent patient satisfaction and rare symptomatic recurrence. Tension-free, intra-
393
abdominal esophageal length can be achieved laparoscopically with esophageal
394
mediastinal mobilization and without the need for esophageal lengthening procedure.
395
The use of PPI for medical management of peptic strictures, a known predictor of
396
shortened esophagus, may have changed the practice of hiatal hernia repair and
397
antireflux surgery. Therefore, the esophageal lengthening procedure with Collis
398
gastroplasty, once an integral part of the surgical management of GERD and hiatal
399
hernia, may become the procedure of the past.
19 Page 19 of 30
400 401
Acknowledgements
402
We would like to acknowledge Dr. Munish Chawla for performing and interpreting the
403
radiographic images for the patients in this study.
404 405
Limitations
406
We acknowledge the limitations of the study, which include a low number of patients
407
and short duration of follow up. In addition, patients may have underrepresented their
408
symptoms or potential dissatisfactions to the operating surgeon, who obtained the
409
questionnaires. The number of recurrent hiatal hernias may also be underestimated
410
since follow-up radiographic studies were not obtained in all patients.
20 Page 20 of 30
411 412
References: 1. Zehetner J, Demeester SR, Ayazi S, Kilday P, Augustin F, Hagen JA, et
413
al.Laparoscopic versus open repair of paraesophageal hernia: the second
414
decade. J Am Coll Surg. 2011 May;212(5): 813-820.
415
2. Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ, et
416
al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair.
417
J Thorac Cardiovasc Surg. 2010 Feb;139(2): 395-404.
418
3. RathoreMA,Andrabi, SI, Bhatti MI, Jajfi SM, McMurray, A. Metaanalysis of
419
Recurrence AfterLaparoscopic Repair of Paraesophageal Hernia.JSLS. 2007
420
Oct-Dec; 11(4): 456-460.
421
4. Banki F, Kaushik C, Roife D, Chawla M, Casimir R, Miller C III. Laparoscopic
422
Redo Antireflux Surgery: A Safe Procedure with High Patient Satisfaction and
423
Low Morbidity.Am J Surg. 2016 (in press).
424
5. Pierre AF, Luketich JD, Fernando HC, Christie NA, Buenaventura PO, Litle VR,
425
et al. Results of laparoscopic repair of giant paraesophageal hernias: 200
426
consecutive patients. Ann Thorac Surg. 2002 Dec;74(6): 1909-1915; discussion
427
1915-6.
428
6. Awais O,Luketich JD, Schuchert MJ, Morse CR, Wilson J, Gooding WE,et
429
al.Reoperative antireflux surgery for failed fundoplication: an analysis of
430
outcomes in 275 patients.Ann Thorac Surg. 2011 Sep;92(3): 1083-1089;
431
discussion 1089-1090.
21 Page 21 of 30
432
7. GastalOL, Hagen JA, Peters JH, Campos GM, Hashemi M, Theisen J, et al.
433
Short esophagus: analysis of predictors and clinical implications.Arch Surg. 1999
434
Jun;134(6): 633-636; discussion 637-638.
435
8. DiazS, Brunt ML, Klingensmith ME, Frisella PM, Soper NJ.Laparoscopic
436
paraesophageal hernia repair, a challenging operation: medium-term outcome of
437
116 patients.J Gastrointest Surg. February 2003, Volume 7(1): 59-67.
438
9. FurneeEJ, Draaisma WA, Broeders IA, Gooszen HG. Surgical reintervention
439
after failed antireflux surgery: a systematic review of the literature.J Gastrointest
440
Surg. 2009 Aug;13(8): 1539-1549.
441
10. Ohnmacht GA, Deschamps C, Cassivi SD, Nichols FS, Allen MS, Schleck CD, et
442
al.Failed Antireflux Surgery: Results After Reoperation.Ann Thorac Surg. 2006;
443
81:2050-2054.
444 445 446
11. vanBeekDB, Auyang ED, Soper NJ. A comprehensive review of laparoscopic redo fundoplication. Surg Endosc. 2011 Mar;25(3): 706-712. 12. Nason, KS, Levy RM, Witteman, BP, Luketich JD.The Laparoscopic Approach to
447
Paraesophageal Hernia Repair.J Gastrointest Surg. 2012 Feb; 16(2): 417-426.
448
13. Granderath FA, Schweiger UM, Kamolz T, Asche KU, Pointner R.Laparoscopic
449
Nissen fundoplication with prosthetic hiatal closure reduces postoperative
450
intrathoracic wrap herniation: preliminary results of a prospective randomized
451
functional and clinical study.Arch Surg. 2005 Jan;140(1):40-48.
452
14. Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective,
453
randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs.
454
simple cruroplasty for large hiatal hernia. Arch Surg. 2002 Jun;137(6):649-52.
22 Page 22 of 30
455
15. Oelschlager BK, Pellegrini CA, Hunter JG, Soper NJ, Brunt ML, Sheppard BC, et
456
al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal
457
hernia repair: a multicenter, prospective, randomized trial. Ann Surg. 2006
458
Oct;244(4): 481-490.
459
16. Oelschlager BK, Pellegrini CA, Hunter JG, Brunt ML, Soper NJ, Sheppard BC, et
460
al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal
461
hernia repair: long-term follow-up from a multicenter, prospective, randomized
462
trial.J Am Coll Surg. 2011 Oct;213(4): 461-468.
463
17. Banki F, Ochoa K, Carrillo ME, Leake SS, Estrera AL, Kahlil K, Safi HJ. A
464
surgical team with focus on staff education in a community hospital improves
465
outcomes, costs and patient satisfaction. Am J Surg. 2013 Dec;206(6):1007-14.
466
23 Page 23 of 30
467
FIGURE LEGEND
468
Figure1. A: Type IV hiatal hernia on videoesophagram. S=Stomach; L=Left lung;
469
SB=Small bowel. B: Laparoscopic view of a type IV hiatal hernia. D=Duodenum;
470
PPV=Prepyloric vein; S=Stomach; RC=Right crus; LC=Left crus.
471 472
Figure 2. A: Type IV hiatal hernia with intrathoracic stomach and herniated small bowel
473
on videoesophagram. S=Stomach with organoaxial volvulus; L=Left lung; SB=Small
474
bowel. B: Laparoscopic view of a type IV hiatal hernia. S=Stomach 100% herniated into
475
the chest cavity; RC=Right crus; LC=Left crus.
476 477
Figure 3. A: Laparoscopic view showing excision of the hernia sac in a patient with type
478
IV hiatal hernia. B: Laparoscopic view of the esophagus after excision of the hernia sac
479
and esophageal mediastinal mobilization in a patient with type IV hiatal hernia.
480
RC=Right crus; S=Spine; E=Esophagus; LP=left pleura.
481 482
Figure 4. A: 2 cm, tension-free, intra-abdominal esophageal length following
483
mediastinal esophageal mobilization without the need for esophageal lengthening in a
484
patient with a type IV hiatal hernia. C=Crural closure; P=Penrose placed around the
485
gastroesophageal junction for retraction; E=Esophagus. B: Laparoscopic view of a
486
Toupet fundoplication (T) placed around a 3 cm, tension-free, intra-abdominal
487
esophagus, following repair of a type IV hiatal hernia. C: Retroflexed endoscopic view of
488
a Toupet fundoplication (T). D: Laparoscopic view of Vicryl mesh placed over the crural
489
closure in a patient with Nissen fundoplication after repair of a type III hiatal hernia. The
24 Page 24 of 30
490
Nissen fundoplication is retracted to the left to expose the mesh. V=Vicryl mesh over the
491
crural closure; RC=Right crus; E=Esophagus; N=Nissen fundoplication.
492 493
Figure 5. This chart shows that at the median follow-up time of 24 months, reoperation-
494
free survival rate was 97% in Toupet and 90% in Nissen (p<0.19).
495 496
25 Page 25 of 30
497
Table 1. Type of hiatal hernia (n=131) Hiatal Hernia Type
N (%)
IV
54 (41.2%) (26 with 100% herniated stomach)
III
37 (28.2%)
I ( ≥ 4 cm) 5 cm (4-5.25)
36 (27.5%)
II 6 cm (5-8)
4 (3.1%)
498 499 500
26 Page 26 of 30
501
Table 2. The 7 most common preoperative primary symptoms (the chief complaint) and
502
the overall preoperative symptoms. Preoperative primary symptom (chief complaint) Dysphagia Heartburn Epigastric pain Regurgitation Chest pain/pressure Anemia Shortness of breath Preoperative overall symptoms Regurgitation Dysphagia Heartburn Epigastric pain Nocturnal cough/choking sensation Chest pain/pressure Anemia Shortness of breath Pneumonia
n ( %) 32 (24%) 30 (23%) 20 (15%) 18 (14%) 16 (12%) 6 (5%) 3 (2%) n ( %) 99 (76%) 88 (67%) 88 (67%) 65 (50%) 52 (40%) 42 (32%) 33 (25%) 21 (16%) 17 (13%)
503 504 505 506 507
27 Page 27 of 30
508
Table 3. Operative data, perioperative complications and postoperative course. Operative time (min) 138 (119-172) Complications
n
Atrial fibrillation
5
Gastric distention or ileus requiring nasogastric tube
5
Blood transfusion
4
Reintubation ( 2/3 had aspiration pneumonia)
3
Delayed esophageal leak
2
Conversion for esophageal perforation by bougie
1
Heparin-induced thrombocytopenia resulting in stroke
1
Temporary dialysis
1
Laparoscopic retrieval of retained Penrose
1
Length of stay (days)
2 (1-3)
30-day or in hospital mortality
none
509 510
28 Page 28 of 30
511
Table 4. Symptomatic questionnaire follow-up via phone obtained in 99/131 (76%)
512
patients at 24 (9-38) months. Questions
N (%)
Free of preoperative symptoms
85/99 (86%)
Satisfied with the operation
91/99 (92%)
Would have undergo the procedure again knowing the current outcome
87/99 (88%)
Could eat as desired
93/99 (94%)
Were able to return to daily activities in less than 2 weeks
74/99 (75%)
Free of typical symptoms of reflux Free of heartburn
92/99 (93%)
Free of regurgitation
88/99 (89%)
Free of dysphagia
87/99 (88%)
Off PPI therapy
73/99 (74%)
Median weight change
0 lbs (-18 to 12)
New onset symptoms Excessive gas
26/99 (26%)
Bloating
19/99 (19%)
Diarrhea
15/99 (15%).
513 514 515
29 Page 29 of 30
516
VIDEO LEGEND
517
Part I: This video demonstrates laparoscopic reduction of type III hiatal hernia,
518
mediastinal esophageal mobilization from the aorta and the pleura, primary crural
519
closure using a Tie-Knot device, Toupet fundoplication, crural closure reinforcement
520
with Vicryl mesh and Evicel to keep the mesh in place. Part II: This video demonstrates
521
laparoscopic mediastinal esophageal mobilization in a patient with a large type IV hiatal
522
hernia, with intrathoracic stomach, herniated omentum and small bowel. A 2-cm,
523
tension-free, intra-abdominal esophageal length is achieved.
524
30 Page 30 of 30