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Paraesophageal hernia repair
Paraesophageal Hernia Repair Nasser K. Altorki, MD
The pathological anatomy of large herniations of the stomach through the esophageal hiatus into the posterior mediastinum is poorly understood. These massive hernias have been termed paraesophageal hernias, total intrathoracic stomachs, and giant hiatal hernias. A precise anatomic definition of such abnormalities would be needless if there were consensus o n the method of operative management. However, controversy persists in the surgical literature regarding 3 salient points: 1. Should repair be accomplished through a transthoracic or a transabdominal approach? The introduction of laparoscopic methods for repair of these large hernias further compounds this controversy. 2. Are these massive hernias associated with true esophageal shortening and if so, should art esophageal lengthening procedure such as a Collis gastroplasty be a key component of their repair? 3. Is gastroesophageal reflux a common feature of the presentation of such hernias, or is it a consequence of a simple anatomic reduction? If so, then an antireflux repair should be another important feature of the surgical strategy. The following discussion presents views of our surgical team with respect to these issues based on an experience with nearly 50 patients who underwent surgical repair of massive hiatal hernias at Cornell Medical College.
DEFINITION A type I, or sliding hiatal hernia, ts considered present when the gastric cardia is displaced cephalad while the remainder of the gastric pouch remains within the abdominal cavity and the phrenoesophageal membrane, though stretched, has no anatomic defects (Fig i). A type II, or rolling hiatal hernia, develops as progressive enlargement of a sliding hernia allows t h e ascent of the
From the New York Hospital CornelI Medical Center, New York, NY. Address repnnt requests to Nasser K. Altorki, MD, The New York Hospital-Cornell Medical Center, 525 East 68th Street, Room P-2212, New York, NY 10021. Copyright 9 2000 by WB. Saunders Company 1524-153X/00/0201-0005510.00/0 doi: 10.1053/gs.2000.5731
fundus alongside the esophagus and the displaced gastroesophageal junction (GEJ). The pressure gradient between the abdomen and the thorax allows progressive enlargement of this type of hernia, whereby the remaining fundus and body of the stomach and even the proximal antrum are displaced into the posterior mediastinum. Because leftward displacement is limited by the descending thoracic aorta and cephalad displacement is limited by the tracheal bifurcation, this large herniation sags into the right chest posterior to the esophagus (Fig 2). Clearly, this type IIA hernia has a significant axial component with the GEJ almost always located in the lower mediastinum. In contrast, a true paraesophageal hernia (an u n c o m m o n entity) occurs only if the esophagogastric junction is securely anchored in the abdomen by the endoabdominal fascia. Our group previously reported on 47 patients with massive hiatal hernias. 1 The precise location of the GEJ was determined using preoperative endoscopic examination and contrast radiography. The GEJ was located in the mediastinum in 82% of patients, lending support to the notion that the majority of such massive hernias represefit the final stage in the evolution of a progressively enlarging sliding hernia. Thus, we believe that surgical correction of these abnormalities should include an antireflux repair. However, in nearly 20% of our patients, the GEJ was located within the abdomen. Some propose that in this latter group a simple transabdomirlal reduction with gastropexy is all that is required, with no need for an antireflux repair. However, evidence from the literature suggests that esophageal manometery and 24-hour pH testing in such cases often reveals objective evidence of an incompetent lower esophageal sphincter and increased esophageal acid exposure. Although our preference is to add an antireflux repair in such instances, a reasonable alternative strategy might include omission of antireflux repair in the absence of objective evidence of reflux. The other 2 points of controversy--the choice of operative approach (transthoracic or transabdominal) and the use or nonuse of a Collis gastroplasty--are interrelated. A popular viewpoint states that sucb masSive hernias are commonly associated with absolute or relative esophageal shortening due to axial and circumferential scarring of the esophageal wall from prolonged
Operative Techniques in General Surgery, Vol 2, No 1 (March), 2000: pp 51-59
51
52
Nasser K. Altorki
~
~ii! ,B
Type I Competent Lower Esophageal Sphincter
Type Reflux
without hernia
f Type II A
Type II
1
Paraesophageal
Types of hiatal hernias. (Reprinted with permission))
2
A type II, or rolling hiatal hernia.
Paraesophageal Hernia Repair
severe acid reflux. Evidence in support of this view was persuasively presented by Maziak and colleagues, 2 who reported on 94 patients with massive hiatal hernias operated on between 1960 and 1996. Nearly 30% of these patients had either an established stricture or grade VI esophagitis. A Collis gastroplasty was carried out in 74 patients to allow a tension-free repair. In contrast, we reported on 47 patients with massive hiatal hernias surgically treated between 1988 and 1997.1 Stage I or II esophagitis was noted endoscopically in 20% of these patients. None of these patients had an established stricture or more severe esophagitis (>grade II). The difference in the prevalence of advanced esophagitis may account for the lack of any appreciation of true shortening in our experience. It is possible that the increased use of proton-pump inhibitors over the past decade may have reduced the severity of reflux-associated esophageal injury. On the other hand, we have commonly encountered situations of "pseudoshortening" whereby the disruption of esophageal attachments at the hiatus allows the esophagus to recoil into the lower or middle mediastinum. The key to successful repair in such instances is a transthoracic approach that allows complete mobilization of the esophagus up to the arch of the aorta. This always results in sufficient esophageal length that allows a tension-free and durable repair.
53
PATIENT SELECTION A N D PREOPERATIVE EVALUATION Every patient with a totally intrathoracic stomach should be carefully considered for surgical repair regardless of the presence or absence of symptoms. Such massive hernias have an acknowledged propensity to produce life-threatening complications such as incarceration, ischemia, perforation, and frank hematemesis. Nearly 30% of our patients required urgent or semiurgent surgical correction. Preoperative evaluation includes an upper gastrointestinal series and upper endoscopy in all patients. Esophageal manometery is usually performed despite the fact that in 30% to 50% of the patients, the catheter cannot be passed across the lower sphincter. However, important information can still be gleaned about the status of esophageal peristalsis, as this may have an important bearing on the choice of antireflux repair. Twenty-four hour pH studies are not routinely performed, because antireflux repair is always a component of the operative repair. Preoperatively, an epidural catheter is placed for postoperative pain management. General anesthesia is induced using a rapid sequence technique to reduce the risk of aspiration. A double-lumen endotracheal tube or a bronchial blocker is used to allow deflation of the left lung. Although not mandatory, single-lung anesthesia greatly improves the exposure.
54
Nasser K. Altorki
SURGICAL TECHNIQUE
i4 i
Latissi~us dorsi musc~le
Serratus anterior muscle
,eventh rib
Pleura~
3 A left thoracotomy incision is performed at the sixth intercostal space, sparing both the serratus anterior muscle and the latissmus dorsi. A 1-cm segment of the seventh rib is resected under cover of the paraspinal fascia to allow for easier retraction of the rib cage. (Reprinted with permission. 4)
Paraesophageal Hernia Repair
4 The massively herniated stomach is seen in the lower mediastinum distending the inferior pulmonary ligament. The inferior pulmonary ligament is divided with the electrocautery, which allows retraction of the left lower lobe superiorly.
5 Because the hernia distorts the anatomy of the cardia, particularly the relationship of both vagus nerves to the hiatus, dissection is begun high in the mediastinum, where both nerves are still intimately related to the esophagus. The esophagus, including both vagus nerves, is encircled with a tape. The esophagus is then mobilized throughout its course in the middle and lower mediastinum. Several maneuvers are key to successful mobilization: division of the middle esophageal artery, division of the left inferior bronchial artery, and blunt mobilization of the esophagus from underneath the aortic arch. Distally, the anterior and posterior hernial sacs are dissected from within the mediastinum and the right chest. The anterior sac is opened at the hiatus by an incision extending from one vagus nerve to the other. The sac is then excised completely, exposing the GEJ and the cardial fat pad. The vagus nerves are carefully protected from injury,
55
Nasser K. Altorki
56
k
' "~,,~--~_~T~_~_~GG-~d I
....
x,__.
6 With the esophagus and stomach retracted anteriorly, the posterior sac is visualized, and as much of it as possible is excised. Again, the vagus nerves are particularly vulnerable during this maneuver. Traction on the esophagus makes both nerves easily palpable as 2 strings proceeding to each side of the hiatus.
I
I
"N.
'~.bl
" I
f
,(
! .... r
-,-,-,\'~,
:,,//~',
7 Following excision of the anterior and posterior sacs, several nonabsorbable sutures are preplaced into the 2 pillars of the right crus of the diaphragm. Because the hiatus may be attenuated from long-standing herniation, the crural sutures should be carefully placed into residual good muscle. With a size 50-52 bougie resting within the esophagus, a transthoracic Nissen fundoplication is then performed. We prefer a 2-cm Nissen fundoplication, because this is an adequate antireflux barrier and prevents possible obstructive symptoms that may result after longer fundoplications.
Paraesophageal Hernia Repair
8 After construction of the fundoplication, the repair is gently reduced into the abdomen. The crural sutures are tied to narrow the crural defect; however, the hiatus should easily admit the index finger. (Reprinted with permission. 4)
57
58
Nasser K. Altorki
,4 2 J
L,/ ./e e
e/
Left F nerve
9 In patients with significantly impaired peristaltic function, a Belsey repair is preferred. The cardial fat pad is excised, and a 2-layer 270 ~ fundoplication is constructed. (Reprinted with permission. 4)
59
Paraesophageal Hernia Repair
DISCUSSION Forty-seven patients underwent surgical repair for massive hiatal hernia at our institution. A transthoracic approach was used in 46 patients; a laparoscopic approach in 1 patient. An antireflux repair was performed in all patients (28 Belsey repairs, i9 Nissen repairs). No patient required an esophageal-lengthening procedure. With a median follow-up time of 64 months. 90% of the patients were either asymptomatic or had only mild, inconsequential symptoms. Anatomic recurrences occurred in three patients (6%) and were symptomatic in 2 of these. These results are comparable to those obtained following repairs accomplished using a Collis gastroplasty, which we believe is unnecessary and potentially hazardous. Leaks through the gastroplasty staple line were reported in at least 2 series and have on occasion resulted either in a prolonged, complicated course or a fatal outcome. The use of laparoscopm approaches to repair these massive hernias is interesting. It is conceivable that laparoscopy may allow enhanced visualization m the mediastinum to delineate the extent of mobilization necessary for a satisfactory outcome. Alternatively, some have advocated new and creative methods of laparoscopic or thoracoscopic creation of a Collis gastroplasty. Necessarily, follow-up in such cases has been short, but if successful, the marginally increased morbidity of gastroplasty may be offset by the rapid recovery often seen after laparoscopic procedures,
REFERENCES 1. Altorki NK, Yankelevitz D. Skinner DB: Massive hiatal hernias: The anatomic basis of repair. J Thorac Cardiovasc Surg 115:828-835, 1998 2. Maziak DE. Todd TRJ, Pearson FG: Massive hiatal hernia: Evaluation and surgical management. J Thorac Cardiovasc Surg 115:5362, 1998 3. Skinner DB, BelseyR: Management of Esophageal Disease. Philadelphia. PA. Vg.B. Saunders. 1988 4. Skinner. DB. Atlas of Esophageal Surgery.. New York. NY. Churchill Livingstone, i991
SUGGESTED READINGS 1. Williamson WA. Ellis FH. Streitz JM et al: Paraesophageal hiatal hernia: Is an anti,reflux procedure necessary? Ann Thorac Surg 56:457-452, 1993 2. Walter B. DeMeester TR. kafontaine E. et al: Effect of paraesophageal hernia on sphincter function and its implication on surgical therapy. AmJ Surg 147:111-116. 1984 3. Allen MS, Trastek VE Deschamps C. et al: Intrathoracie stomach. J Thorac Cardiovasc Surg 105:253-259, 1993 4. Pearson FG. Cooper JD, Patterson GA_ et al: Gastroplasty and fundoplication for complex reflux problems. Ann Surg 206:473. 1987 5. Fuller CB, Hagen JA, DeMeester TR. et al: The role of fundoplication in the treatment of type II paraesophageal hernia. J Thorac Cardiovasc Surg 111:655-66i. 1996
The pathological anatomy of large herniations of the stomach through the esophageal hiatus into the posterior mediastinum is poorly understood. These massive hernias have been termed paraesophageal hernias, total intrathoracic stomachs, and giant hiatal hernias. A precise anatomic definition of such abnormalities would be needless if there were consensus o n the method of operative management. However, controversy persists in the surgical literature regarding 3 salient points: 1. Should repair be accomplished through a transthoracic or a transabdominal approach? The introduction of laparoscopic methods for repair of these large hernias further compounds this controversy. 2. Are these massive hernias associated with true esophageal shortening and if so, should art esophageal lengthening procedure such as a Collis gastroplasty be a key component of their repair? 3. Is gastroesophageal reflux a common feature of the presentation of such hernias, or is it a consequence of a simple anatomic reduction? If so, then an antireflux repair should be another important feature of the surgical strategy. The following discussion presents views of our surgical team with respect to these issues based on an experience with nearly 50 patients who underwent surgical repair of massive hiatal hernias at Cornell Medical College.
DEFINITION A type I, or sliding hiatal hernia, ts considered present when the gastric cardia is displaced cephalad while the remainder of the gastric pouch remains within the abdominal cavity and the phrenoesophageal membrane, though stretched, has no anatomic defects (Fig i). A type II, or rolling hiatal hernia, develops as progressive enlargement of a sliding hernia allows t h e ascent of the
From the New York Hospital CornelI Medical Center, New York, NY. Address repnnt requests to Nasser K. Altorki, MD, The New York Hospital-Cornell Medical Center, 525 East 68th Street, Room P-2212, New York, NY 10021. Copyright 9 2000 by WB. Saunders Company 1524-153X/00/0201-0005510.00/0 doi: 10.1053/gs.2000.5731
fundus alongside the esophagus and the displaced gastroesophageal junction (GEJ). The pressure gradient between the abdomen and the thorax allows progressive enlargement of this type of hernia, whereby the remaining fundus and body of the stomach and even the proximal antrum are displaced into the posterior mediastinum. Because leftward displacement is limited by the descending thoracic aorta and cephalad displacement is limited by the tracheal bifurcation, this large herniation sags into the right chest posterior to the esophagus (Fig 2). Clearly, this type IIA hernia has a significant axial component with the GEJ almost always located in the lower mediastinum. In contrast, a true paraesophageal hernia (an u n c o m m o n entity) occurs only if the esophagogastric junction is securely anchored in the abdomen by the endoabdominal fascia. Our group previously reported on 47 patients with massive hiatal hernias. 1 The precise location of the GEJ was determined using preoperative endoscopic examination and contrast radiography. The GEJ was located in the mediastinum in 82% of patients, lending support to the notion that the majority of such massive hernias represefit the final stage in the evolution of a progressively enlarging sliding hernia. Thus, we believe that surgical correction of these abnormalities should include an antireflux repair. However, in nearly 20% of our patients, the GEJ was located within the abdomen. Some propose that in this latter group a simple transabdomirlal reduction with gastropexy is all that is required, with no need for an antireflux repair. However, evidence from the literature suggests that esophageal manometery and 24-hour pH testing in such cases often reveals objective evidence of an incompetent lower esophageal sphincter and increased esophageal acid exposure. Although our preference is to add an antireflux repair in such instances, a reasonable alternative strategy might include omission of antireflux repair in the absence of objective evidence of reflux. The other 2 points of controversy--the choice of operative approach (transthoracic or transabdominal) and the use or nonuse of a Collis gastroplasty--are interrelated. A popular viewpoint states that sucb masSive hernias are commonly associated with absolute or relative esophageal shortening due to axial and circumferential scarring of the esophageal wall from prolonged
Operative Techniques in General Surgery, Vol 2, No 1 (March), 2000: pp 51-59
51
52
Nasser K. Altorki
~
~ii! ,B
Type I Competent Lower Esophageal Sphincter
Type Reflux
without hernia
f Type II A
Type II
1
Paraesophageal
Types of hiatal hernias. (Reprinted with permission))
2
A type II, or rolling hiatal hernia.
Paraesophageal Hernia Repair
severe acid reflux. Evidence in support of this view was persuasively presented by Maziak and colleagues, 2 who reported on 94 patients with massive hiatal hernias operated on between 1960 and 1996. Nearly 30% of these patients had either an established stricture or grade VI esophagitis. A Collis gastroplasty was carried out in 74 patients to allow a tension-free repair. In contrast, we reported on 47 patients with massive hiatal hernias surgically treated between 1988 and 1997.1 Stage I or II esophagitis was noted endoscopically in 20% of these patients. None of these patients had an established stricture or more severe esophagitis (>grade II). The difference in the prevalence of advanced esophagitis may account for the lack of any appreciation of true shortening in our experience. It is possible that the increased use of proton-pump inhibitors over the past decade may have reduced the severity of reflux-associated esophageal injury. On the other hand, we have commonly encountered situations of "pseudoshortening" whereby the disruption of esophageal attachments at the hiatus allows the esophagus to recoil into the lower or middle mediastinum. The key to successful repair in such instances is a transthoracic approach that allows complete mobilization of the esophagus up to the arch of the aorta. This always results in sufficient esophageal length that allows a tension-free and durable repair.
53
PATIENT SELECTION A N D PREOPERATIVE EVALUATION Every patient with a totally intrathoracic stomach should be carefully considered for surgical repair regardless of the presence or absence of symptoms. Such massive hernias have an acknowledged propensity to produce life-threatening complications such as incarceration, ischemia, perforation, and frank hematemesis. Nearly 30% of our patients required urgent or semiurgent surgical correction. Preoperative evaluation includes an upper gastrointestinal series and upper endoscopy in all patients. Esophageal manometery is usually performed despite the fact that in 30% to 50% of the patients, the catheter cannot be passed across the lower sphincter. However, important information can still be gleaned about the status of esophageal peristalsis, as this may have an important bearing on the choice of antireflux repair. Twenty-four hour pH studies are not routinely performed, because antireflux repair is always a component of the operative repair. Preoperatively, an epidural catheter is placed for postoperative pain management. General anesthesia is induced using a rapid sequence technique to reduce the risk of aspiration. A double-lumen endotracheal tube or a bronchial blocker is used to allow deflation of the left lung. Although not mandatory, single-lung anesthesia greatly improves the exposure.
54
Nasser K. Altorki
SURGICAL TECHNIQUE
i4 i
Latissi~us dorsi musc~le
Serratus anterior muscle
,eventh rib
Pleura~
3 A left thoracotomy incision is performed at the sixth intercostal space, sparing both the serratus anterior muscle and the latissmus dorsi. A 1-cm segment of the seventh rib is resected under cover of the paraspinal fascia to allow for easier retraction of the rib cage. (Reprinted with permission. 4)
Paraesophageal Hernia Repair
4 The massively herniated stomach is seen in the lower mediastinum distending the inferior pulmonary ligament. The inferior pulmonary ligament is divided with the electrocautery, which allows retraction of the left lower lobe superiorly.
5 Because the hernia distorts the anatomy of the cardia, particularly the relationship of both vagus nerves to the hiatus, dissection is begun high in the mediastinum, where both nerves are still intimately related to the esophagus. The esophagus, including both vagus nerves, is encircled with a tape. The esophagus is then mobilized throughout its course in the middle and lower mediastinum. Several maneuvers are key to successful mobilization: division of the middle esophageal artery, division of the left inferior bronchial artery, and blunt mobilization of the esophagus from underneath the aortic arch. Distally, the anterior and posterior hernial sacs are dissected from within the mediastinum and the right chest. The anterior sac is opened at the hiatus by an incision extending from one vagus nerve to the other. The sac is then excised completely, exposing the GEJ and the cardial fat pad. The vagus nerves are carefully protected from injury,
55
Nasser K. Altorki
56
k
' "~,,~--~_~T~_~_~GG-~d I
....
x,__.
6 With the esophagus and stomach retracted anteriorly, the posterior sac is visualized, and as much of it as possible is excised. Again, the vagus nerves are particularly vulnerable during this maneuver. Traction on the esophagus makes both nerves easily palpable as 2 strings proceeding to each side of the hiatus.
I
I
"N.
'~.bl
" I
f
,(
! .... r
-,-,-,\'~,
:,,//~',
7 Following excision of the anterior and posterior sacs, several nonabsorbable sutures are preplaced into the 2 pillars of the right crus of the diaphragm. Because the hiatus may be attenuated from long-standing herniation, the crural sutures should be carefully placed into residual good muscle. With a size 50-52 bougie resting within the esophagus, a transthoracic Nissen fundoplication is then performed. We prefer a 2-cm Nissen fundoplication, because this is an adequate antireflux barrier and prevents possible obstructive symptoms that may result after longer fundoplications.
Paraesophageal Hernia Repair
8 After construction of the fundoplication, the repair is gently reduced into the abdomen. The crural sutures are tied to narrow the crural defect; however, the hiatus should easily admit the index finger. (Reprinted with permission. 4)
57
58
Nasser K. Altorki
,4 2 J
L,/ ./e e
e/
Left F nerve
9 In patients with significantly impaired peristaltic function, a Belsey repair is preferred. The cardial fat pad is excised, and a 2-layer 270 ~ fundoplication is constructed. (Reprinted with permission. 4)
59
Paraesophageal Hernia Repair
DISCUSSION Forty-seven patients underwent surgical repair for massive hiatal hernia at our institution. A transthoracic approach was used in 46 patients; a laparoscopic approach in 1 patient. An antireflux repair was performed in all patients (28 Belsey repairs, i9 Nissen repairs). No patient required an esophageal-lengthening procedure. With a median follow-up time of 64 months. 90% of the patients were either asymptomatic or had only mild, inconsequential symptoms. Anatomic recurrences occurred in three patients (6%) and were symptomatic in 2 of these. These results are comparable to those obtained following repairs accomplished using a Collis gastroplasty, which we believe is unnecessary and potentially hazardous. Leaks through the gastroplasty staple line were reported in at least 2 series and have on occasion resulted either in a prolonged, complicated course or a fatal outcome. The use of laparoscopm approaches to repair these massive hernias is interesting. It is conceivable that laparoscopy may allow enhanced visualization m the mediastinum to delineate the extent of mobilization necessary for a satisfactory outcome. Alternatively, some have advocated new and creative methods of laparoscopic or thoracoscopic creation of a Collis gastroplasty. Necessarily, follow-up in such cases has been short, but if successful, the marginally increased morbidity of gastroplasty may be offset by the rapid recovery often seen after laparoscopic procedures,
REFERENCES 1. Altorki NK, Yankelevitz D. Skinner DB: Massive hiatal hernias: The anatomic basis of repair. J Thorac Cardiovasc Surg 115:828-835, 1998 2. Maziak DE. Todd TRJ, Pearson FG: Massive hiatal hernia: Evaluation and surgical management. J Thorac Cardiovasc Surg 115:5362, 1998 3. Skinner DB, BelseyR: Management of Esophageal Disease. Philadelphia. PA. Vg.B. Saunders. 1988 4. Skinner. DB. Atlas of Esophageal Surgery.. New York. NY. Churchill Livingstone, i991
SUGGESTED READINGS 1. Williamson WA. Ellis FH. Streitz JM et al: Paraesophageal hiatal hernia: Is an anti,reflux procedure necessary? Ann Thorac Surg 56:457-452, 1993 2. Walter B. DeMeester TR. kafontaine E. et al: Effect of paraesophageal hernia on sphincter function and its implication on surgical therapy. AmJ Surg 147:111-116. 1984 3. Allen MS, Trastek VE Deschamps C. et al: Intrathoracie stomach. J Thorac Cardiovasc Surg 105:253-259, 1993 4. Pearson FG. Cooper JD, Patterson GA_ et al: Gastroplasty and fundoplication for complex reflux problems. Ann Surg 206:473. 1987 5. Fuller CB, Hagen JA, DeMeester TR. et al: The role of fundoplication in the treatment of type II paraesophageal hernia. J Thorac Cardiovasc Surg 111:655-66i. 1996