Paraesophageal Hernia
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1 Paraesophageal Hernia Inderpal (Netu) S. Sarkaria, M.D. Vice Chairman, Clinical Affairs Director, Robotic Thoracic Surgery Co-Director, Esophageal and Lung Surgery Institute
2 Speaker/Education: Intuitive Surgical
3 Types of Hiatal Hernias Type I Type III Type II Organoaxial volvulus
4 Typical Esophagram of Giant PEH Intrathoracic Stomach
5 Clinical Presentation Asymptomatic Air-fluid level on CXR Pain Postprandial fullness Nausea Regurgitation Anemia Emergent
6 Evaluation Endoscopy Barium radiography Manometry? Computed Tomography? Acute Setting Laboratory (acid-base/electrolyte derangements, sepsis)
7 Acutely symptomatic patients (toxic) require open surgery Laparotomy if there is no evidence of chest contamination Left thoracotomy if there is evidence of gastric necrosis with chest contamination
8 Natural History of Giant Hernia PEH patients followed for a decade 21% presented with strangulation Mortality of emergency repair (17%) Mortality with elective repair (<5%) All patients with giant HH should be repaired Skinner DB, Belsey RH; J Thorac Cardiovasc Surg Jan;53(1):33.
9 Surgical Principles Re-establish normal anatomy! Atraumatic hernia reduction Obtain tension free intra-abdominal esophageal length Complete excision of hernia sac High mediastinal dissection Clear anatomic confirmation of GEJ - Esophageal fat pad dissection Crural preservation Atraumatic handling and dissection preserve the peritoneal lining Vagal preservation Tension free crural repair Mobilization of crura Suture reinforcement? Pledgets? Crural reinforcement/reconstruction? Mesh? Esophageal lengthening? Collis? Decrease diaphragmatic tension? Decrease intraperitoneal pressure? Induce pneumothorax? Gastrofundoplication
10 Mediastinal Dissection Many structures in confined space Inferior pulmonary vein Azygous vein Right atrium Airway (right and left mainstem, carina) Pleural spaces Aorta IVC Difficult visualization augments the problem
11 Thoracic Approach Able to mobilize more esophagus Avoid the need for Collis gastroplasty
12 Maziak and Pearson. Open Repair of Giant PEH with Collis Gastroplasty and Belsey. Annals Surgery patients with intra-thoracic stomach (type III) operated upon over a 20 year period Operative approach Left thoracotomy Sac excision Collis lengthening procedure for shortened esophagus No deaths, 1% leak rate 91% with good results, 9% with fair results At a mean follow-up of 10 years only 2 re-operations required Sets the gold-standard for outcomes
13 10-year retrospective, Belsey vs Laparoscopic 118 Belsey matched 1:1 (year, gender, age) Recurrence similar: 8.4% vs 16.1% Wedge gastroplasty protective of recurrence Esophageal leak higher with Nissen: 0% v 6.8% Higher reoperation with Nissen: 2.5% v 9.3% GERD HRQL similar Single surgeon vs multiple surgeons
14 UPMC GPEH Experience 662 patients Median age 70 (range 19-92) 30 day mortality 1.7% (11 patients) Quality of Life 90% good to excellent results Reoperation 3.2% (21) Compatible with gold-standard open series Luketich et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. JTCVS 2010
15 Laparoscopic Hand over Hand Reduction of Intrathoracic Stomach Atraumatic Reduction of Stomach
16 Hernia sac Laparoscopic Sac Dissection and Excision Hiatal opening
17 Assessment of Esophageal Length Cardia location
18 Esophageal Lengthening May not be required with good mobilization and high mediastinal dissection
19 Fundoplication and Crural Repair
20 GPEH: Initial View Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
21 GPEH: Initial Sac Retraction Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
22 GPEH: Initial Sac Dissection Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
23 GPEH: Mediastinal Dissection Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
24 GPEH: Pleural Rent Closure Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
25 GPEH: Mediastinal Dissection Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
26 Collis Nissen
27 Collis-Nissen Robotic Stapler 3:00; 6:00; 7:20
28 Thank You Inderpal S. Sarkaria, MD Vice Chairman, Clinical Affairs Director, Robotic Thoracic Surgery Co-Director, Esophageal & Lung Surgery Institute University of Pittsburgh Medical Center
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