Laparoscopic giant hiatal hernia repair

Abstract

Giant hiatal hernias are generally defined as those hernias with greater than 50% of the stomach above the diaphragm (see radiograph). The term giant hiatal hernia includes the majority of type III hiatal hernias. Altorki 1 and Pearson 2 have reported that the gastroesophageal junction in most patients with giant type II and III hernias is located above the diaphragmatic hiatus, indicating that most arise from progressive enlargement of a classic type I sliding hiatal hernia. Open repair of an intrathoracic stomach is accomplished via left thoracotomy or upper midline laparotomy. Successful outcomes, epitomized by the series of Maziak and coworkers, 2 have established the principles for success: complete hernia sac excision, tension-free reduction of the stomach, ensuring an intraabdominal length of esophagus of at least 2.5 cm, preservation of crural integrity, and secure crural repair. Minimally-invasive techniques have been applied to the repair of giant hiatal hernias, but have been associated with recurrence rates of up to 30 to 40% compared with 5 to 10% for open repair. 3,4 Such high rates of recurrent herniation may be due, at least in part, to technical acclimatization to the laparoscopic environment (“learning curve”). Failure to recognize and properly treat acquired shortening of the esophagus is also a likely source of recurrence. The short esophagus is diagnosed intraoperatively when less than 2 cm of esophagus remains intraabdominal under tension-free conditions after complete mobilization. Pearson found that 80% of patients undergoing repair of massive hiatal hernias had significant degrees of shortening. 2 A Collis procedure should be applied in such patients to create an adequate length of intraabdominal (neo-) esophagus to minimize the propensity for reherniation. In a series of 200 laparoscopic giant paraesophageal hernia repairs, Luketich performed Collis gastroplasty as a component of the repair in 112 patients. 5 The recurrence rate in this series was only 2.7%. Jobe reported no recurrences at 14 months in a series of 15 patients undergoing Collis gastroplasty with fundoplication for type III hiatal hernia. 6