Laparoscopic Repair of Large Paraesophageal Hiatal Hernia Peter S. Dahlberg, MD, Claude Deschamps, MD, Daniel L. Miller, MD, Mark S. Allen, MD, Francis C. Nichols, MD, and Peter C. Pairolero, MD Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota Background. The objective of this study was to analyze our initial results after laparoscopic repair of large paraesophageal hiatal hernias. Methods. Between October 1997 and May 2000, 37 patients (23 women, 14 men) underwent laparoscopic repair of a large type II (pure paraesophageal) or type III (combined sliding and paraesophageal) hiatal hernia with more than 50% of the stomach herniated into the chest. Median age was 72 years (range 52 to 92 years). Data related to patient demographics, esophageal function, operative techniques, postoperative symptomatology, and complications were analyzed. Results. Laparoscopic hernia repair and Nissen fundoplication was possible in 35 of 37 patients (95.0%). Median hospitalization was 4 days (range 2 to 20 days). Intraoperative complications occurred in 6 patients (16.2%) and included pneumothorax in 3 patients, splenic injury in 2, and crural tear in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating in 2, and a small bowel obstruction in 1. Two patients died within 30 days (5.4%), 1 from delayed splenic bleeding and 1 from adult respiratory distress syndrome secondary to a recurrent strangulated hiatal hernia. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Twenty-seven patients (87.1%) were improved. Four patients (12.9%) required early postoperative dilatation. Recurrent paraesophageal hiatal hernia occurred in 4 patients (12.9%). Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%). Conclusions. Laparoscopic repair of large paraesophageal hiatal hernias is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach. (Ann Thorac Surg 2001;72:1125 9) 2001 by The Society of Thoracic Surgeons Traditional surgical treatment of large diaphragmatic hiatal hernia (LDHH) has been performed either through a thoracotomy or laparotomy approach. Although laparoscopy became common more than 10 years ago, controversy still exists regarding the indications for this approach in management of LDHH. The purpose of this report is to describe our initial experience with laparoscopic hernia repair and Nissen fundoplication for these type II and type III LDHH. Material and Methods Between October 1997 and May 2000, 224 patients underwent laparoscopic Nissen fundoplication at the Mayo Clinic in Rochester, MN. Thirty-seven (16.5%) of these patients underwent repair of a LDHH (greater than 50% of the stomach in the chest). Records of these 37 patients were reviewed for age, gender, type of hernia, operative Presented at the Poster Session of the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29 31, 2001. Address reprint requests to Dr Deschamps, Division of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, 200 First St, SW, Rochester, MN 55905; e-mail: deschamps.claude@mayo.edu. morbidity and mortality, and functional outcome. Data were acquired from the patients medical record and from follow-up phone interviews. The patient functional status was considered excellent if symptoms were absent without medication; good either if symptoms were mild without medication or if dysphagia required only one postoperative esophageal dilatation; fair if symptoms were controlled with medication or periodical dilatations; and poor if symptoms were unimproved or warranted reoperation. All hernias were classified according to the method of Skinner [1]. At operation, all patients were placed in a dorsal lithotomy position. Pneumoperitoneum was instituted with carbon dioxide insufflation. A total of five ports were utilized, with the locations being in the supraumbilical, right flank, epigastrium, left subcostal, and left flank regions. A 30-degree Storz rigid laparoscope (Karl Storz, Tuttlingen, Germany) was placed through the supraumbilical port and the liver retractor through the right flank. The surgeon utilized the epigastrium and the left subcostal ports to perform the operation while the assistant retracted the stomach through the left flank. The gastrohepatic ligament was partially divided near the hiatus and the crura were mobilized. After reduction of the 2001 by The Society of Thoracic Surgeons 0003-4975/01/$20.00 Published by Elsevier Science Inc PII S0003-4975(01)02972-1
1126 DAHLBERG ET AL Ann Thorac Surg LAPAROSCOPIC REPAIR OF LARGE PARAESOPHAGEAL HIATAL HERNIA 2001;72:1125 9 hernia, the sac was resected and the crura were reapproximated posteriorly using nonabsorbable sutures. If needed, anterior crura sutures were utilized to close the hiatal defect. On one occasion, a polytetrafluoroethylene patch (Gore-Tex; W. L. Gore & Associates, Flagstaff, AZ) was used to close a large anterior defect. The short gastric vessels were divided in all patients with the Harmonic Scalpel LCS (Ultra Cision, Smithfield, RI), and a Nissen fundoplication was performed over a 50 or 58 Fr bougie in the esophagus using two or three nonabsorbable sutures. The length of the approximated fundoplication measured between 1.5 and 2 cm. The vagus nerves were identified with minimal manipulation in all patients and were included in the fundoplication. All ports were closed in layers under direct vision using absorbable sutures. Most repairs were performed in the morning and the patient was allowed to have a liquid diet the night of the operation and a soft diet the next morning. Clinical Findings The group consisted of 22 (59.5%) women and 15 (40.5%) men. Median age at the time of repair was 67 years and ranged from 52 to 92 years. No patient had a previous operation for either gastroesophageal reflux disease (GERD) or a hiatal hernia. Eleven patients (29.8%) had a prior laparotomy for conditions unrelated to the LDHH. Indications for previous laparotomy included cholecystectomy and hysterectomy in 2 patients, cholecystectomy and appendectomy, hysterectomy, splenectomy, colectomy, cholecystectomy, appendectomy, and umbilical hernia in 1 each. Indications for previous laparotomy were unknown in 2 patients. Signs or symptoms were present in all 37 patients and included heartburn in 25 (67.6%), dysphagia in 13 (35.1%), anemia in 12 (32.4%), early satiety in 9 (24.3%), dyspnea in 7 (18.9%), asthma in 6 (16.2%), weight loss in 4 (10.8%), aspiration in 2 (5.4%), and regurgitation, chest pain, abdominal discomfort/bloating in 11 each (29.7%). Two patients had a prior esophageal dilatation. Preoperative medication for GERD included proton pump inhibitors in 23 patients (62.2%) and H 2 blockers in 4 (10.8%). Preoperative evaluation included esophagoscopy in 35 patients (94.6%), barium swallow in 27 (73.0%), esophageal motility in 13 (35.1%), and a 24-hour ph study in 3 (8.1%). All 35 patients undergoing endoscopy had a hiatal hernia. Esophagitis was present in 7 patients (18.9%), and a stricture was present in 2 (5.4%). Barrett s disease was documented histologically in 3 patients (8.1%). Barium swallow demonstrated a paraesophageal hiatal hernia in 18 patients (48.6%), combined sliding and paraesophageal hernia in 9 (24.3%), and reflux in 3 (8.1%). Esophageal motility findings included normal peristalsis in 11 patients (29.7%) and decreased peristalsis in 2 (5.4%). All 3 patients undergoing 24-hour ph analysis had ph below 4 for an extended period of time. At operation, all 37 patients had a paraesophageal hiatal Table 1. Complications Complications Number (%) Intraoperative Pneumothorax 3 (8.1) Splenic injury 2 (5.4) a Crura laceration 1 (2.7) Postoperative Dysphagia 2 (5.4) Esophageal leak 2 (5.4) Small bowel obstruction 1 (2.7) Symptomatic gastric herniation 3 (8.1) a a Cause of death in 1 patient each. hernia that was classified as type II in 25 (67.6%) and type III in 12 (32.4%). Results All 37 patients were initially explored through a laparoscopic approach. Two patients (5.4%) were converted to an open procedure and were excluded from further analysis. The reason for conversion was adhesions from a previous laparotomy in 1 patient and bleeding from the spleen in the other. A 360-degree Nissen fundoplication was performed in the 35 remaining patients. Two patients had additional procedures; 1 had a cut Collis gastroplasty and the other had a cholecystectomy. Median operating time was 179 minutes and ranged from 110 to 315 minutes. Intraoperative complications (Table 1) occurred in 6 patients (16.2%) and included pneumothorax in 3, splenic injury in 2, and crura laceration in 1. Early postoperative complications occurred in 5 patients (13.5%) and included esophageal leak in 2, severe bloating requiring nasogastric decompression in 2, and a small bowel obstruction at a port site requiring reoperation in 1. Two patients (5.4%) died within 30 days of operation; 1 from delayed splenic bleeding and another from adult respiratory distress syndrome. Postmortem examination revealed retroperitoneal, liver, and splenic lymphoma in 1 patient and a recurrent strangulated hiatal hernia in the other. Median hospitalization for all 35 patients was 4 days and ranged from 2 to 20 days. Follow-up was complete in 31 patients (94.0%) and ranged from 3 to 34 months (median 15 months). Four patients (12.9%) required early esophageal dilatation (within the first 3 postoperative months); none required dilatation subsequently. Barium swallow was performed in 22 patients (71.0%) after an average postoperative period of 3.2 months (range 0 to 13 months). Nineteen examinations (86.4%) were interpreted as normal; 3 demonstrated an anatomical recurrence of the hiatal hernia, 2 of which required reoperation. An uncut Collis-Nissen fundoplication was performed 6 days after the initial laparoscopic repair in 1 patient and an esophagogastrectomy 3.5 months after the initial laparoscopic repair in the other because of necrosis at the esophagogastric junction. The third patient had a
Ann Thorac Surg DAHLBERG ET AL 2001;72:1125 9 LAPAROSCOPIC REPAIR OF LARGE PARAESOPHAGEAL HIATAL HERNIA 1127 Table 2. Late Results Symptoms/Signs Excellent Good Fair Poor None 17......... Reflux... 2...... Dysphagia... 4...... Bloating... 2 1... Diarrhea... 1... Recurrent DH... 1... 3 Total 17 (54.9%) 9 (29.0%) 1 (3.2%) 4 (12.9%) DH diaphragmatic hernia. small asymptomatic recurrence and is being observed. Another patient was found to have a symptomatic epiphrenic diverticulum 18 months after laparoscopic repair. This was successfully repaired through a left thoracotomy, where a myotomy and excision of the diverticulum was performed. Overall, 27 patients (87.1%) were improved. Functional results were classified as excellent in 17 patients (54.9%), good in 9 (29.0%), fair in 1 (3.2%), and poor in 4 (12.9%) (Table 2). Comment Laparoscopic Nissen fundoplication has become the standard surgical treatment for patients with uncomplicated GERD. While many of these patients have an associated hiatal hernia, it is usually small and repair is generally straightforward (reduction of the hernia, approximation of the diaphragmatic crura, and fundoplication). Although a technical learning curve is associated with this operation [2], long-term results are excellent in a majority of patients [3, 4]. In contrast, surgical management of LDHH is controversial. The goals of repair are anatomic reduction of the hernia and a competent lower esophageal sphincter, and both can be accomplished either transabdominally or transthoracically [5]. Successful reduction of the hernia may require extensive dissection with mobilization of both the esophagus and stomach, and the hernia sac must be completely resected from the mediastinum [6]. Crural approximation and fundoplication should be an inherent part of the repair to prevent anatomical recurrence and postoperative GERD [3, 5, 7, 8]. Gastrostomy and gastropexy have also been used to anchor the stomach in the abdomen [3, 9, 10]. More recently, closure of the diaphragmatic defect with prosthetic material has been proposed [11 13]. The success of laparoscopy for achalasia and GERD makes it tempting to offer laparoscopic approach to an increasing number of patients with LDHH (Table 3). Potential patient-related benefits are possible with a laparoscopic approach that include shorter hospitalization and less postoperative pain [2]. Preliminary reports also suggest that the functional outcome is similar to that after open repair (Table 3). Several factors make the laparoscopic repair of LDHH more difficult, which include preoperative comorbidities, body habitus, the propensity for some hernias to incarcerate and strangulate, the necessity of excising the sac without damage to neighboring structures [6], and adequate closure of a large hiatus [3, 10, 14]. Like others [15], we have identified a high prevalence of recurrent hernia on early radiographic investigation of patients. Inadequate crural closure and sac excision are the technical factors most often associated with recurrent Table 3. Other Reported Series Author Year Patients Conversion Number (%) Type of Repair Mortality Number (%) Follow-up (Months) Recurrent Hernia (%) Results a Oddsdottir 1995 10 0 Nissen b 0 9 10% 89% Huntington 1997 58 1 (1.7%) Nissen/Toupet 1 (1.7%) 12 0% f 100% Willekes 1997 30 0 Nissen/Toupet c 0... 0% 100% Perdikis 1997 65 2 (3.0%) Nissen/Toupet 0 18 15% 93% Krahenbuhl 1998 12 1 (8%) Nissen d 0 21... 92% Edye 1998 55... Nissen/Toupet 0 29 14.5% 85% Schauer 1998 67 3 (4%) Nissen/Toupet 1 (1.5%) 13... 94% Gantert 1998 55 5 (9%) Various e 1 (1.8%) 11 4% 89% Wu 1999 38 1 (2.6%) Nissen/Toupet 2 (5%) 24 15% g 95% Horgan 1999 41 2 (5%) Nissen/Toupet 1 (2.5%) 36 5% 100% Hashemi 2000 27... Nissen 0 17 42% 77% Mayo 2001 37 2 (5.4%) Nissen 2 (5.4%) 13 12% 84% a Excellent and good. b One patient had a gastropexy. c Two patients had gastropexy. d Gastropexy added in all patients. e Nissen, 270-degree wrap, gastropexy. f Based on symptoms only. g Three other patients had intrathoracic wraps.
1128 DAHLBERG ET AL Ann Thorac Surg LAPAROSCOPIC REPAIR OF LARGE PARAESOPHAGEAL HIATAL HERNIA 2001;72:1125 9 herniation [16]. Other factors include slippage of the fundoplication or a fundoplication that is too tight [17]. In our series, acute recurrent herniation occurred in 4 patients, and each was believed to result from breakdown of the crural closure. The optimal technique for closure of a large crural defect is also controversial. Basso and associates [18] cited excessive tension of the crural closure as the cause of breakdown. They modified their closure to include posterior placement of polypropylene mesh [19]. Others have advocated the use of polytetrafluoroethylene because it may allow tissue ingrowth without stimulating excessive adhesion formation [20]. Others have cautioned against using prosthetic material because of concerns of excessive adhesion formation and erosion into esophagus with respiratory motions [21]. We have utilized prosthetic reconstruction in only 1 patient. Authors who examined early recurrences after laparoscopic repair have attributed recurrence to inadequate excision of the hernia sac [16]. While the sac was removed in all of our patients, our series does not directly address the most appropriate method of diaphragmatic closure. We have found, however, that lowering intraperitoneal gas pressure or creating an iatrogenic pneumothorax intraoperatively does decrease tension on the crura and facilitates closure. However, if a secure closure of the crura cannot be performed laparoscopically, the operation should be converted to an open procedure. Equally as important, failure to recognize and manage a shortened esophagus is associated with an increased risk of postoperative herniation [22]. The esophagogastric junction must be reduced to below the diaphragm without tension. Others have suggested that a gastroplasty be added to an antireflux procedure if the repair alone results in tension on the fundoplication [23, 24]. A majority of our patients had either excellent or good functional outcome after laparoscopic repair of LDHH. Those results are similar to that reported by others (Table 3). But, as with other surgical procedure, a period of learning is required [2, 3, 25]. We believe that as experience is gained, morbidity will be less and a higher percentage of patients will have good to excellent results. In summary, we conclude that laparoscopic repair of LDHH is a challenging operation associated with significant morbidity and mortality. More experience, longer follow-up, and further refinement of the operative technique is indicated before it can be recommended as the standard approach. References 1. Skinner DB. Esophageal hiatal hernia. The condition: clinical manifestations and diagnosis. In: Sabiston DC Jr, Spencer FC, eds. Surgery of the chest, 5th ed. Philadelphia: WB Saunders, 1990:890 902. 2. Deschamps C, Allen MS, Trastek VF, Johnson JO, Pairolero PC. Early experience and learning curve associated with laparoscopic Nissen fundoplication. J Thorac Cardiovasc Surg 1998;115:281 5. 3. Soper NJ. Laparoscopic management of hiatal hernia and gastroesophageal reflux. Curr Probl Surg 1999;36:767 838. 4. Valiati W, Fuchs KH, Valiati L, J et al. Laparoscopic fundoplication: short- and long-term outcome. Langenbeck s Arch Surg 2000;385:324 8. 5. Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic stomach. Presentation and results of operation. J Thorac Cardiovasc Surg 1993;105:253 9. 6. Watson DI, Davies N, Devitt PG, Jamieson GG. Importance of dissection of the hernia sac in laparoscopic surgery for large hiatal hernias. Arch Surg 1999;134:1069 71. 7. Trastek VF, Allen MS, Deschamps C, Pairolero PC, Thompson A. Diaphragmatic hernia and associated anemia: response to surgical treatment. J Thorac Cardiovasc Surg 1996; 112:1340 5. 8. Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 1998;115:53 60. 9. Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of paraesophageal hiatal hernias. J Am Coll Surg 1998;186: 428 33. 10. Oddsdottir M, Franco AL, Laycock WS, Waring JP, Hunter JG. Laparoscopic repair of paraesophageal hernia. New access, old technique. Surg Endosc 1995;9:164 8. 11. Koger KE, Stone JM. Laparoscopic reduction of acute gastric volvulus. Am Surg 1993;59:325 8. 12. Carlson MA, Richards CG, Frantzides CT. Laparoscopic prosthetic reinforcement of hiatal herniorrhaphy. Dig Surg 1999;16:407 10. 13. Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc 1997;11:769 71. 14. Cuschieri A, Shimi S, Nathanson LK. Laparoscopic reduction, crural repair and fundoplication of large hiatal hernia. Am J Surg 1992;163:425 30. 15. Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective follow-up reveals high recurrence rate. J Am Coll Surg 2000;190:553 61. 16. Edye M, Salky B, Posner A, Fierer A. Sac excision is essential to adequate laparoscopic repair of paraesophageal hernia. Surg Endosc 1998;12:1259 63. 17. Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication failures; patterns of failure and response to fundoplication revision. Ann Surg 1999;230:595 606. 18. Basso N, Rosato P, De Leo A, Genco A, Rea S, Neri T. Tension-free hiatoplasty, gastrophrenic anchorage, and 360 fundoplication in the laparoscopic treatment of paraesophageal hernia. Surg Laparos Endosc 1999;9:257 62. 19. Basso N, De Leo A, Genco A, et al. 360 laparoscopic fundoplication with tension-free hiatoplasty in the treatment of symptomatic gastroesophageal reflux disease. Surg Endosc 2000;14:164 9. 20. Paul MG, DeRosa RP, Petrucci PE, Palmer ML, Danovitch SH. Laparoscopic tension-free repair of large paraesophageal hernias. Surg Endosc 1997;11:303 7. 21. Trus TL, Hunter JG. Minimally invasive surgery of the esophagus and stomach. Am J Surg 1997;173:242 55. 22. Yau P, Watson DI, Jamieson GG, Myers J. The influence of esophageal length on outcomes after laparoscopic fundoplication. J Am Coll Surg 2000;191:360 5. 23. Darling G, Mackay M. The Belsey Mark IV and Collis-Belsey fundoplications. In: Deschamps C, ed. Operative techniques in general surgery. Repair of esophageal hiatal hernias. Philadelphia: WB Saunders, 2000;2:60 81. 24. Jobe BA, Hovath KD, Swanstrom LL. Postoperative function following laparoscopic Collis gastroplasty for shortened esophagus. Arch Surg 1998;133:867 74. 25. Horgan S, Eubanks TR, Jacobsen G, Omelanczuk, Pellegrini CA. Repair of paraesophageal hernias. Am J Surg 1999;177: 354 8. 26. Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophaegal hernia repair. Arch Surg 1997;132:586 90. 27. Schauer PR, Ikramuddin S, McLaughlin RH, et al. Compar-
Ann Thorac Surg DAHLBERG ET AL 2001;72:1125 9 LAPAROSCOPIC REPAIR OF LARGE PARAESOPHAGEAL HIATAL HERNIA 1129 ison of laparoscopic versus open repair of paraesophageal hernia. Am J Surg 1998;176:659 65. 28. Wu JS, Dunnegan DL, Soper NJ. Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair. Surg Endosc 1999;13:497 502. 29. Edye M, Canin-Endres J, Gattorno F, Salky BA. Durability of laparoscopic repair of paraesophageal hernia. Ann Surg 1998;118:528 35. 30. Willekes CI, Edoga JK, Frezza E. Laparoscopic repair of paraesophageal hernia. Ann Surg 1997;225:31 8. 31. Huntington TR. Short-term outcome of laparoscopic paraesophageal hernia repair. Surg Endosc 1997;11:894 8. 32. Krahenbuhl L, Schafer M, Farhadi J, Renzulli P, Seiler CA, Buchler MW. Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach. J Am Coll Surg 1998;187:231 7. INVITED COMMENTARY The article by Dahlberg and associates represents an important contribution to the literature of a difficult problem on a controversial topic. It is important because this article discusses not whether laparoscopic repair of large esophageal lesions can be done, but whether or not they should be done. The group at the Mayo Clinic has clearly demonstrated that laparoscopic repair of a large paraesophageal hiatal hernia is possible, but more importantly, they have reported with honesty and integrity the early and intermediate results. Initial reports of laparoscopic surgery for this entity indicate only that the procedure is able to be done in almost all patients, however, only with few exceptions are there any longterm results reported for open repairs of paraesophageal hernias let alone laparoscopic approaches. Their results show that there is a significant number of intraoperative complications with this procedure even in the most experienced of hands. A recurrence rate of 4 patients was seen, however, only 22 of the 35 patients in the study were evaluated with a postoperative barium swallow. This is significantly higher than reported for transthoracic repair of a paraesophageal hiatal hernia. The overall functional results were similar to other large series, since many of these patients have abnormal gastric emptying and esophageal motility prior to operation. The key points identified for recurrence or failure with this technique are: (1) inadequate crural closure; (2) inadequate excision of the sack and mobilization of the stomach; and (3) difficulty with crural reapproximation. It is important to realize that this is an early report involving a formidable problem with a new technique. Like any new procedure, this will require a significant learning curve which should be carried out only by those with the ability to perform advanced laparoscopic surgery as well as the ability to treat the complications as well as the expertise to perform esophageal reconstruction. It is only with this honest and unbiased reporting of experience as exemplified by the Mayo group that we will truly learn whether this is technology advancing patient care or simply the advancement of technology for technology s sake. Mark D. Iannettoni, MD Section of Thoracic Surgery University of Michigan 1500 E Medical Center Dr 2120 Taubman Center, Box 0344 Ann Arbor, MI 48109 e-mail: mdi@umich.edu. 2001 by The Society of Thoracic Surgeons 0003-4975/01/$20.00 Published by Elsevier Science Inc PII S0003-4975(01)03126-5