Paraconduit herniation - Invited editorial

Abstract

Minimally invasive esophageal surgery is becoming increasingly common as the advantages of minimizing tissue disruption and bleeding are recognized. The embracement of new technology inevitably results in a change in the frequency and type of complications seen. In this edition, De Silva et al.1 highlights the increased incidence of para-conduit hiatal herniation after minimally invasive esophagectomy. This complication is well recognized in the UK, with centers reporting a higher rate of para-conduit herniation after performing minimally invasive techniques. The authors of this paper have reported the frequency of this problem across two high volume centers in Australia. The theory is that after minimally invasive surgery, there are less abdominal adhesions, which would normally prevent the free movement of intrabdominal viscera through the widened mediastinum. In contrast, during open abdominal upper gastrointestinal surgery, tissue trauma leads to the formation of adhesions in the upper abdomen, fixing structures within the abdominal cavity. It is clear that adhesion formation is important, but there are a few other factors that should be considered. For example, does the herniation occur immediately after surgery when adhesions have not yet formed? Or is it a result of pulling the conduit through into the chest? Our experience is that hernias can occur early and are sometimes in the presence of previous upper abdominal surgery.