Paraesophageal Hiatal Hernia Repair Research Articles

Risk factors associated with radiological and clinical recurrences after laparoscopic repair of large hiatal hernia with TiO2Mesh™ reinforcement.

Laparoscopic repair of large para-esophageal hiatal hernias (LPHH) remains controversial. Several meta-analyses suggest hiatus reinforcement with mesh has better outcomes over cruroplasty in terms of less recurrence. The aim of this study was to evaluate the medium-term results of treating LPHH with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™). A retrospective observational study, using data extracted from a prospectively collected database was performed at XXX from December 2014 to June 2023. Included participants were all patients who underwent laparoscopic repair of large (> 5cm) type III hiatal hernia in which a TiO2Mesh™ was used. The results of the study, including clinical and radiological recurrences as well as mesh-related morbidity, were analyzed. Sixty-seven patients were finally analyzed. Laparoscopic approach was attempted in all but conversion was needed in one patient because of bleeding in the lesser curvature. With a median follow-up of 41months (and 10 losses to follow-up), 22% of radiological recurrences and 19.3% of clinical recurrences were described. Regarding complications, one patient presented morbidity associated with the mesh (mesh erosion requiring endoscopic extraction). Recurrent hernia repair was an independent factor of clinical recurrence (OR 4.57 95% CI (1.28-16.31)). LPHH with TiO2Mesh™ is safe and feasible with a satisfactory medium-term recurrence and a low complication rate. Prospective randomized studies are needed to establish the standard repair of LPHH.

Robotic-assisted versus laparoscopic paraesophageal hernia repair: a systematic review and meta-analysis.

The robotic approach offers improved visualization and maneuverability for surgeons. This systematic review aims to compare the outcomes of robotic-assisted and conventional laparoscopic approaches for paraesophageal hernia repair, specifically examining postoperative complications, operative time, hospital stay, and recurrence. A systematic review including thorough research through PubMed, Scopus, and Cochrane, was performed and only comparative studies were included. Studies concerning other types of hiatal hernias or children were excluded. A meta-analysis was conducted to compare overall postoperative complications, hospital stay, and operation time. Ten comparative studies, with 186,259 participants in total, were included in the meta-analysis, but unfortunately, not all of them reported all the outcomes under question. It appeared that there is no statistically significant difference between the conventional laparoscopic and the robotic-assisted approach, regarding the overall postoperative complication rate (odds ratio [OR], 0.56, 95% confidence interval [CI], 0.28-1.11), the mean operation time (t = 1.41; 95% CI, -0.15-0.52; p = 0.22), and the hospital length of stay (t = -1.54; degree of freedom = 8; 95% CI, -0.53-0.11; p = 0.16). Only two studies reported evidence concerning the recurrence rates. Overall, the robotic-assisted method did not demonstrate superiority over conventional laparoscopic paraesophageal hiatal hernia repair in terms of postoperative complications, operation time, or hospital stay. However, some studies focused on cost and patient characteristics of each group. Further comparative and randomized control studies with longer follow-up periods are needed for more accurate conclusions on short- and long-term outcomes.

A Narrative Review on Treatment of Giant Hiatal Hernia.

Background: The current gold standard of treatment for giant hiatal hernias (GHHs) is laparoscopic surgery. Laparoscopic surgery was performed as a less invasive procedure for paraesophageal hernias more than 25 years ago. Its viability and safety have almost all been shown. Materials and Methods: A review of recent and current studies' literature was done. Prospective randomized trials, systematic reviews, clinical reviews, and original articles were all investigated. The data were gathered in the form of a narrative evaluation. We examine the state of laparoscopic GHH repair today and outline the GHH management strategy. Results: In this review, we clear up misunderstandings of GHH and address bad habits that may have contributed to poor results, and we have consequently performed a methodical evaluation of GHH. First, we address subcategorizing GHH and provide criteria to define them. The preoperative workup strategies are then discussed, with a focus on any pertinent and frequent atypical symptoms, indications for surgery, timing of surgery, and the importance of surgery. The approach to the techniques and the logic behind surgery are then presented along with some important dissection techniques. Finally, we debate the role of mesh reinforcement and evaluate the data in terms of recurrence, reoperation rate, complications, and delayed stomach emptying. Finally, we suggest a justification for common postoperative investigations. Conclusions: Surgery is the only effective treatment for GHH at the moment. If the right operational therapy principles are applied, this is generally successful. There is a growing interest in laparoscopic paraesophageal hiatal hernia repair as a result of the introduction of laparoscopic antireflux surgery. Today's less invasive procedures provide a better therapeutic choice with a lower risk.

Similar hospital profits with robotic-assisted paraesophageal hiatal hernia repair, despite higher or supply costs.

Robotic-assisted laparoscopic surgery has emerged as an alternative to traditional laparoscopy and may offer some clinical benefits when performing complex hiatal hernia repairs. Many institutions may choose to not invest in robotic surgery because of perceived higher costs, and when they already have proficient laparoscopic surgeons. We hypothesized that the robotic approach would yield lower profits overall due to higher supply costs, while offering comparable outcomes to the traditional laparoscopic approach. Financial and outcomes data from a single quaternary academic center was retrospectively reviewed from a prospectively collected database from July 2020 to May 2021. Laparoscopic hiatal hernia repairs and robotic-assisted repairs were compared for metrics including length of stay, operative time, hospital and supply cost, payments, and profits. Metrics of these two groups were compared using t-test analyses with significance set to p < 0.05. Seventy-three patients were included with 31 in the robotic group (42.5%) and 42 in the laparoscopic group (57.5%). There were no significant differences in length of stay (robotic mean 2.0days, laparoscopic 2.55days, p = 0.09) or operative time (257.6min vs 256.7min, p = 0.48) between the two approaches. The robotic approach was associated with higher supply costs ($2,655 vs $2,028, p < 0.001) and patient charges ($63,997 vs $56,276, p < 0.05). Despite higher costs associated with robotics, hospital profits were not different between the two groups ($7,462 vs $7,939, p = 0.42). Despite higher supply costs and charges for robotic-assisted hiatal hernia repair, hospital profits were similar when comparing robotic and laparoscopic approaches. Short-term clinical outcomes were also similar. Programs should do their own analysis to understand their individual cost issues.

Novel "starburst" mesh configuration for paraesophageal and recurrent hiatal hernia repair: comparison with keyhole mesh configuration.

Controversy exists over the use of mesh, its type and configuration in repair of hiatal hernia. We have used biological mesh for large or recurrent hiatal hernias. We have developed a mesh configuration to better enhance the tensile strength of the hiatus by folding the mesh over the edge of the hiatus-entitled the "starburst" configuration. We report our experience with the starburst configuration, comparing it to our results with the keyhole configuration. Medical records of all patients undergoing either the keyhole or starburst mesh configuration hiatal hernia repair were reviewed between 2017 and 2021. Data gathered included age, sex, type of hernia (sliding, paraesophageal, or recurrent), fundoplication type (none, Nissen, Toupet, Dor, Collis-Nissen, Collis-Toupet, or magnetic sphincter augmentation [MSA]), 30-day complications, and long-term outcomes (hiatal hernia recurrence, reflux-symptom recurrence, dysphagia, dilations, reoperations). From 7/2017 to 8/2019, 51 cases using the keyhole mesh were completed. Sliding hiatal hernia comprised 4%, paraesophageal hernia (PEH) 64% and recurrent hiatal hernia (RHH) 34% of cases. Distribution of fundoplication type: 2% none, 41% Nissen, 41% Toupet, 8% Dor, 2% Collis-Nissen, and 6% Collis-Toupet. 30-day complication rate 31%. Long-term outcomes: recurrent hiatal hernia 16%, dysphagia 12%, dysphagia requiring dilation(s) 10%, recurrent GERD symptoms 4%, and reoperation 14%. From 10/2020 to 8/2021, 58 cases using the starburst configuration were completed. PEH comprised 60% and RHH 40%. Distribution of fundoplication type: 10% none, 40% Nissen, 43% Toupet, 5% MSA, 2% Collis-Toupet. 30-day complication rate 16%. Long-term outcomes: recurrent hiatal hernia 19%, dysphagia 14%, dilations 5%, recurrent GERD symptoms 9%, and reoperations 3%. The starburst mesh configuration compares favorably with the keyhole configuration with respect to postoperative dysphagia, need for esophageal dilation, and GERD symptom recurrence, with similar recurrence rates. We are continuing to further refine this technique and study the long-term outcomes.

Observational medical treatment or surgery for giant paraesophageal hiatal hernia in elderly patients.

Giant paraesophageal hernias (GPHH) occur frequently in the elderly and account for about 5-10% of all hiatal hernias. Up to now controversy persists between expected medical treatment and surgical treatment. To assess if an indication for surgical repair of GPHH is possible in elderly patients. A prospective study that includes patients over 70 years of age hospitalized from January 2015 to December 2019 with GPHH. Patients were separated into Group A and Group B. Group A consisted of a cohort of 23 patients in whom observation and medical treatment were performed. Group B consisted of 44 patients submitted to elective laparoscopic hiatal hernia repair. Symptomatic patients were observed in both groups (20/23 in Group A and 38/44 in Group B). Charlson's score >6 and ASA II or III were more frequent in Group A. Patients in Group A presented symptoms many years before their hospitalization in comparison to Group B (21.8+7.8 vs. 6.2+3.5 years, respectively) (P=0.0001). Emergency hospitalization was observed exclusively in Group A. Acute complications were frequently observed and hospital stays were significantly longer in Group A, 14 patients were subjected to medical management and 6 to emergency surgery. In-hospital mortality occurred in 13/20 patients (65%) versus 1/38 patients (2.6%) in Group B (P=0.0001). Laparoscopic paraesophageal hiatal hernia repair can be done safely, effectively, and in a timely manner in elderly patients at specialized surgical teams. Advanced age alone should not be a limiting factor for the repair of paraesophageal hernias.

Application of robotic surgery for paraesophageal hiatal hernia repair: a narrative review

Application of robotic surgery for paraesophageal hiatal hernia repair: a narrative review

Paraesophageal hernia repair with laparoscopic Toupet fundoplication: impact on pulmonary function, respiratory symptoms and quality of life.

Paraesophageal hiatal hernia (PEH) is characterized by protrusion of intra-abdominal organs into the posterior mediastinum. Respiratory symptoms and reduced pulmonary function have been described as possibly related to lung compression. To assess the effect of laparoscopic Toupet fundoplication (LTF) for PEH repair on pulmonary function, measured with pulmonary function tests (PFTs), and respiratory symptoms. Retrospective, single-center, cohort study (November 2015-2020). All patients that completed pre- and postoperative (12months) PFTs assessment were included. The gastroesophageal reflux disease health-related quality of life (GERD-HRQL), reflux symptom index (RSI) and short form-36 (SF-36) were used. Overall, 71 patients were included. The median age was 67.1years and the majority were females (78.8%). Baseline PFTs were within normal limits in 91% of patients. At 12month follow-up, total lung capacity (TLC) (4.77 vs. 5.07 L; p = 0.0251), vital capacity (VC) (2.97 vs. 3.31 L; p = 0.0065), forced expiratory volume in one second (FEV1) (2.07 vs. 2.44 L; p < 0.001) and forced vital capacity (FVC) (2.78 vs. 3.19 L; p < 0.001) were significantly improved. No significant differences were found for diffusing capacity of lung for carbon monoxide (DLCO) (17.09 vs. 17.24; p = 0.734), and FEV1/FVC (0.77 vs. 0.77; p = 0.967). Interestingly, improvements were more pronounced in patients with large PEH (type IIIb and IV). At 12month follow-up, both gastrointestinal and respiratory symptoms were significantly improved and 94% of patients were satisfied with the operation. The GERD-HRQL (18.1 ± 7.9 vs. 4.01 ± 2.4; p = 0.001), RSI (37.8 ± 9.7 vs. 10.6 ± 8.9; p < 0.001) and all SF-36 items were improved. LTF for the treatment of PEH is safe and seems to be effective up to 12month follow-up with improved lung volumes, spirometry values, quality of life, gastrointestinal and respiratory symptoms.

Translation of Legislation: Effect Analysis of Michigan Opioid Law on Clinical Practice

BackgroundTo combat almost 450,000 Americans dying of opioid overdose between 1999 and 2018, the Michigan Opioid Laws were implemented on July 1, 2018, to reduce overprescription of opioids. This retrospective study evaluated the effect of this legislation on prescribing patterns after thoracic operations at an academic, tertiary care center. MethodCharts of 776 patients undergoing lobectomy, paraesophageal hiatal hernia repair, Nissen fundoplication, or esophagectomy between July 1, 2017, and July 1, 2019, were reviewed. Populations were identified before and after the July 1, 2018 implementation of the Michigan Opioid Laws. Procedure type, analgesic type, total pills, morphine equivalents, and refills and their pill number were independent variables. Patients using opioids for >30 days before operations were excluded. ResultsOverall, 629 patients were included in the analysis (324 pre-legislation patients, 305 post-legislation patients). The average number of opioids prescribed to patients at discharge before the legislation was 28.0 pills vs 21.4 pills after (P < .01). Before implementation of the Michigan Opioid Laws, 14.5% of patients received refills, whereas only 5.9% received refills after implementation, reducing the average number of refills per patient from 0.19 to 0.07 (P < .001). Average morphine equivalents and percentage of patients receiving opioids showed no statistical difference. ConclusionsThe implementation of the Michigan Opioid Laws correlated with a change in clinical practice, potentially by reducing the number of pills and refills prescribed per patient, and did not deter providers from prescribing opioids acutely. This suggests that the Michigan Opioid Laws allow prescribing freedom while giving legislative structure encouraging time-conscious tapering. The Michigan Opioid Laws may serve as a model for other states to emulate.

Choosing the best approach for paraesophageal hiatal hernia repair: a narrative review

Choosing the best approach for paraesophageal hiatal hernia repair: a narrative review

634 ROBOTIC-ASSISTED HIATAL HERNIA AND GASTROESOPHAGEAL DISEASE SURGERY: INITIAL RESULTS AND EXPERIENCE IN A SINGLE INSTITUTION

Abstract Gastroesophageal reflux disease, associated with sliding or large paraesophageal hiatal hernia, represents a common disease that frequently needs a surgical solution. The repair of large paraesophageal hiatal hernias is still a challenge in minimally invasive surgery but the robotic approach seems to gain widespread acceptance because offers enhanced visualization, dexterity and reach, which may facilitate the hiatal reconstruction and mediastinal dissection. Methods Between June 2019 and February 2021, 23 patients (5 male, 18 female) underwent robotic approach fundoplication (19 sliding hernia, 3 paraesophageal and 2 gastroesophagic reflux) after being pre operative diagnosed. All surgeries were elective. Biosynthetic tissue absorbable mesh was applied in one patient with double time recurrence hernia. Sixteen patients underwent total fundoplication (Nissen), 6 patients had Toupet fundoplication, and one patient had hiatus repair without fundoplication. Results The mean age of the patients was 61 years. Biosynthetic mesh was used in one patient. The mean operative time was 127 minutes (80-240) and no intraoperative complications were described. There were no conversions to open or laparoscopic procedures. Nine of the twenty-three patients underwent redo hiatal hernia repairs and the mean hospital stay was 2 days. Only one patient had a major complication (Clavien Dindo 3b) requiring urgent surgery. The early and 30 day mortality rate was 0%. Conclusion In our experience, robotic approach to paraesophageal repair seems safe and effective with low complication rates even in high-risk patients and those with redo surgery. Subjectively, the robotic approach provides the surgeon better vision and maneuverability during the intervention. We hope to progressively increase the number of robotic cases to analyse long-term clinical outcomes such as hiatal hernia recurrences, need of medical therapy and quality of life.

S1474 Acute Pancreatitis as an Early Complication of Laparoscopic Sleeve Gastrectomy

INTRODUCTION: Bariatric surgery remains a safe and effective long term solution to help curb the growing obesity problem worldwide. Laparoscopic sleeve gastrectomy (LSG) is the most common surgical intervention performed. Acute pancreatitis (AP) is a rarely reported complication. Herein we present a case of AP within 30 days of LSG. CASE DESCRIPTION/METHODS: A 27-year-old morbidly obese female underwent LSG and paraesophageal hiatal hernia repair after complete outpatient evaluation. On post-op day (POD) 2, she was discharged home upon tolerating a liquid diet. She presented to the Emergency Department (ED) four days later with multiple episodes of diarrhea and lethargy. Stool studies did not reveal any infection. She was hydrated and discharged home. On POD 16, she returned with nausea and inability to tolerate solid food but denied any abdominal pain. Her lipase was elevated at 511 U/L. However, CT Abdomen with contrast was normal. She was advised to stay hydrated and discharged with antiemetics. She was re-evaluated twice more for similar complaints and on her 5th ED visit on POD 26, she was admitted for severe nausea and poor oral intake. Patient still denied abdominal pain but endorsed some regurgitation. She appeared dehydrated and her abdominal exam was benign. Labs revealed WBC 12000/µL, Creatinine 0.8 mg/dL, normal bilirubin/liver enzymes, and Lipase 687 U/L. Repeat CT Abdomen showed inflammation of the posterior pancreas and a normal gallbladder. Esophagogastroduodenoscopy revealed Hill Grade III gastroesophageal flap valve and gastritis at the junction of the gastric body and antrum without stricture or leak. Patient was aggressively hydrated the first day and subsequently started on total parenteral nutrition. Her lipase peaked at 785 U/L but she clinically improved and was discharged home 3 days later. She did well on follow-up without any sequelae. DISCUSSION: AP is an under-recognized complication associated with any bariatric surgery. In a retrospective study by Hussan et al, they reported a 2-fold increase in AP risk within 6 months after LSG when compared to other bariatric surgeries. There are many hypotheses for this potentially life-threatening complication including gallstones, postprandial peak of cholecystokinin promoting the release of pancreatic enzymes, peripancreatic tissue adhesion intraoperatively, or compromised pancreatic microcirculation. As the number of LSG performed annually continues to increase, a high index of suspicion should remain for AP as a potential early complication.

Short-Term Outcomes in Patients Undergoing Paraesophageal Hiatal Hernia Repair

Many patients with hiatal hernias (HH) are asymptomatic; however, symptoms may include heartburn, regurgitation, dysphagia, nausea, or vague epigastric pain depending on the hernia type and severity. The ideal technique and timing of repair remains controversial. This report describes short-term outcomes and readmissions of patients undergoing HH repair at our institution. All patients who underwent HH repair from January 2012 through April 2017 were reviewed. Patients undergoing concomitant bariatric surgery were excluded. 239 patients were identified and 128 were included. Eighty-eight were female (69%) and 40 were male (31%) with a mean age of 59 years (range 20–91 years) and a mean BMI of 29.2 kg/m2 (17–42). Worsening GERD was the most common presenting symptom in 79 (61.7%) patients. Eighty-four laparoscopic cases (65.6%) and 44 robotic assisted (34.4%) procedures were performed. Mesh was used in 59 operations (3 polytetrafluoroethylene; 56 biologic). All hiatal hernia types (I-IV) were collected. Majority were initial operations (89%). Techniques included: Toupet fundoplication in 68 cases (63.0%), Nissen fundoplication in 36 (33.3%), Dor fundoplication in 4 (3.7%), concomitant Collis gastroplasty in 4 (3.1%), and primary suture repair in 20 (15.6%). Outcomes between robotic and laparoscopic procedures were compared. Length of stay was reported as median and interquartile range for laparoscopic and robotic: 1.0 day (1.0–3.0) and 2.0 days (1.0–2.5); p = 0.483. Thirty-day readmission occurred in 9 patients, 7 (8.3%) laparoscopic and 2 (4.6%) robotic; p = 0.718. Two 30-day reoperations occurred, both laparoscopic; p = 0.545. Total of 16 complications occurred; 18.6% had a complication with the use of mesh compared to 8.7% without the use of mesh, p = 0.063. There were no conversion to open modality and no mortalities were reported. Hiatal hernia repair can be performed safely with a low incidence of complications.

Evolution From the U-shaped to Keyhole-shaped Mesh Configuration in the Repair of Paraesophageal and Recurrent Hiatal Hernia.

Paraesophageal hernia (PEH) and recurrent hiatal hernia (RHH) are prone to recurrences. One adjunct used to reduce recurrences is mesh reinforcement. The optimal configuration is yet to be determined. We present our evolution from the U-shaped to the keyhole pattern. All patients undergoing PEH/RHH repair with mesh between 2013 and 2019 were reviewed for demographic information, perioperative/intraoperative details, postoperative complications, and recurrences. Of patients undergoing PEH/RHH repair between 2013 and 2019, 138 were repaired using mesh. Of these, 88 were repaired using the U-shaped configuration and 50 using the keyhole configuration. The U-shaped configuration was used for PEH in 72% and RHH in 28%, while the keyhole configuration was used for PEH in 66% and RHH in 34%. Thirty patients suffered postoperative complications, although there was no difference between the groups. Overall, 28 patients in the U-shaped configuration group (31.8%) had a recurrence of their hiatal hernia identified, compared with 7 patients (14.6%) in the keyhole group (P=0.039). The median time to last follow-up was 21 months (range: 1 to 85) in the U-shaped group and 8 months (range: 1 to 23) in the keyhole group. There was no difference in median time to recurrence, postoperative dysphagia, dilations, or strictures. The keyhole pattern mesh was not associated with a higher complication rate compared with the U-shape pattern. Although this study was not a direct comparison between the configurations, it does suggest that the keyhole pattern may lead to fewer recurrences.

Laparoscopic gastric fundus tamponade: a novel adaptation of the Toupet fundoplication for large paraesophageal hernia repair.

Laparoscopic repair of large paraesophageal hiatal hernia with defects too large to close primarily or greater than 8cm is technically challenging. The ideal repair remains unclear and is often debated. Utilizing the gastric fundus as an autologous patch to obliterate and tamponade large hiatal defects may offer a new solution. The aim of this study was to evaluate the short-term outcomes following partial posterior fundoplication with gastric fundus tamponade. Retrospective chart review and prospective patient follow up was conducted on patients who underwent laparoscopic hiatal hernia repair between 2015 and 2019 by a single surgeon. Basic demographics, pre-operative diagnoses, operative technique, and clinical outcomes were recorded. Fifteen patients underwent the described technique for repair of large paraesophageal hiatal hernia. All procedures were completed laparoscopically with a short post-operative length of stay (mean of 3days) and no 30-day readmissions. The majority of patients reported resolution of their pre-operative symptoms. Only one patient required surgery for emergent indications and the same patient was the only mortality in the study, which was secondary to respiratory failure, necrotizing pneumonia, and sepsis as a result of gastric volvulus and obstruction. Utilizing the gastric fundus as an autologous patch to repair large hiatal hernia may be a safe and efficacious solution with good short-term outcomes. However, further studies should be conducted to elucidate long-term results.

Assessment of short-term outcome with TiO2 mesh in laparoscopic repair of large paraesophageal hiatal hernias

BackgroundLaparoscopic large para-oesophageal hiatal hernia (LPHH) repair using mesh reinforcement significantly reduces postoperative recurrence rates compared to conventional suture repair, especially within short follow-up times. However, the ideal strategy for repairing LPHH remains disputable because no clear guidelines are given regarding indications, mesh type, shape or position. The aim of this study was to survey our short-term results of LPHH management with a biosynthetic monofilament polypropylene mesh coated with titanium dioxide to enhance biocompatibility (TiO2Mesh™).MethodsA retrospective study was performed at Ramon y Cajal University Hospital, Spain from December 2014 to October 2018. Data were collected on 27 consecutive patients with extensive hiatal hernia defects greater than 5 cm for which a laparoscopic repair was performed by primary suture and additional reinforcement with a TiO2Mesh™. Study outcomes were investigated, including clinical and radiological recurrences, dysphagia and mesh-related drawbacks.ResultsTwenty-seven patients were included in our analysis; 10 patients were male, and 17 were female. The mean age was 73 years (range, 63–79 years). All operations were performed laparoscopically. The median postoperative hospital stay was 3 days. After a mean follow-up of 18 months (range, 8-29 months), only 3 patients developed clinical recurrence of reflux symptoms (11%), and 2 had radiological recurrences (7%). No mesh-related complications occurred.ConclusionsTiO2Mesh™ was found to be safe for laparoscopic repair of LPHH with a fairly low recurrence rate in this short-term study. Long-term studies conducted over a period of years with large sample sizes will be essential for confirming whether this mesh is suitable as a standard method of care with few drawbacks.

A162 Investigation of Laparoscopic Sleeve Gastrectomy with and without concurrent Paraesophageal Hiatal Hernia Repair utilizing the ACS MBSAQIP

A162 Investigation of Laparoscopic Sleeve Gastrectomy with and without concurrent Paraesophageal Hiatal Hernia Repair utilizing the ACS MBSAQIP

Short Hospital Stay and Low Recurrence Rates with Robot-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair: An Improvement on Both Transthoracic and Laparoscopic Approaches

Short Hospital Stay and Low Recurrence Rates with Robot-Assisted Laparoscopic Paraesophageal Hiatal Hernia Repair: An Improvement on Both Transthoracic and Laparoscopic Approaches

Minimally invasive surgery for large hiatal hernia.

The majority of large hiatal hernias are paraesophageal hiatal hernias (PEH). Once prolapse of the stomach to the chest cavity reaches a high degree, it is called an intrathoracic stomach. More than 25 years have elapsed since laparoscopic surgery was carried out as minimally invasive surgery for PEH. The feasibility and safety thereof has nearly been established. PEH may cause serious complications such as strangulation and perforation. The outcome of elective repair of PEH is better than emergent repair, so we should carry out elective repair as much as possible. Although not a major clinical problem, following PEH repair the rate of anatomical recurrence increases with age. In order to reduce the recurrence rate, mesh reinforcement by crural repair has been widely performed. Although this improves the short‐term outcomes, the long‐term outcomes are unclear. For PEH repair, fundoplication and gastropexy are believed desirable. We should select the procedure associated with a lower incidence of dysphagia and so on following surgery. While relaxing incision is useful for primary tension‐free closure, it has not contributed to improvement in the recurrence rate.

The other explanation for dyspnea: giant paraesophageal hiatal hernia repair routinely improves pulmonary function

Paraesophageal hiatal hernias (PEHs) are most commonly associated with gastrointestinal symptoms; less widely appreciated is their potentially important influence on respiratory function. We hypothesize that surgical repair of PEH will significantly improve not only gastrointestinal symptoms, but also preoperative dyspnea and spirometry scores. A prospective Institutional Review Board-approved database was used to review all patients undergoing PEH repair from 2000 to 2016. Patients with pre- and postoperative pulmonary function tests assessed by spirometry were included. Postoperative changes in spirometry measurements were compared to PEH size as reflected by the percentage of intrathoracic stomach observed on preoperative contrast studies. Patients were stratified according to improvement in forced expiratory volume in 1 second (FEV1). Patients with >12% ('significant') improvement in FEV1 after surgery were compared to the remaining patient population. In total, 299 patients met the inclusion criteria. Symptomatic improvement in respiratory function was noted in all patients after PEH repair. Age, gender, BMI, presenting symptoms, Charlson comorbidity index as well as preoperative comorbidities did not significantly impact the functional outcome. Spirometry results improved in 80% of the patients, 21% of whom showed an improvement of >20% compared to the preoperative level. 'Significant' improvement in respiratory function was seen in 122 of 299 (41%) patients. Patients presenting with moderate and severe preoperative pulmonary obstruction demonstrated 'significant' improvement in FEV1 in 48% and 40% of cases, respectively. Large PEHs, characterized by a percentage of intrathoracic stomach >75%, was strongly associated with 'significant' improvement in FEV1 (P = 0.001). PEHs can impact subjective and objective respiratory status and surgical repair can result in a significant improvement in dyspnea and pulmonary function score that is independent of preoperative pulmonary disease. Gastric herniation of more than 75% was associated with higher possibility for improvement of pulmonary function tests. Patients with persistent and unexplained dyspnea and coexistent PEH should be assessed by an experienced surgeon for consideration of elective repair.