Laparoscopic Laparoscopic Paraesophageal Hiatal Paraesophageal Hiatal

Hernia Repair and Hernia Repair and FundoplicationFundoplication

Lawrence Way, MDLawrence Way, MD

Paraesophageal HH: The Paraesophageal HH: The IssuesIssues

Anatomy.Anatomy. Natural history.Natural history. Symptoms and syndromes.Symptoms and syndromes. Indications for operation.Indications for operation. The operation:The operation:

– How often is there a short esophagusHow often is there a short esophagus– How to deal with the sacHow to deal with the sac– How should we close the hiatal openingHow should we close the hiatal opening– Should a fundoplication be includedShould a fundoplication be included– Prevention of reherniationPrevention of reherniation

Patient #1: 69 y.o. womanPatient #1: 69 y.o. woman

Heartburn x15 y. PPIs relief. UGI: PEH. No pH monitoring.

Types I, II, III, IV: AnatomyTypes I, II, III, IV: Anatomy

II Sliding hiatal herniaSliding hiatal hernia

IIII Pure paraesophageal HH; GEJ in Pure paraesophageal HH; GEJ in the normal position.the normal position.

III, IVIII, IV Mixed paraesophageal Mixed paraesophageal

IV is III plus another organ IV is III plus another organ herniated herniated

The pocket (sack) develops first to the left of the esophagus, which allows the fundus to herniate first. The sack then enlarges anterior to the esophagus, so the body of the stomach eventually rolls upward (volvulus) as it enters the chest anterior to the fundus and esophagus.

Paraesophageal Hiatal Paraesophageal Hiatal HerniaHernia

Type IIFundus in the chest; GEJ in the abdomen

Type IIIFundus and GEJ in the chest

Type IIIEntire stomach and GEJ in the chest.

Type IIIFundus returns to the abdomen; antrum still in the chest

The distinction between II and III is more theoretical than real. Actually, whenever there is a paraesophageal component, the GEJ usually moves cephalad with the fundus (ie, they all are type III). The distinction between these types on radiographs is unreliable. The notion that Type III is commonly associated with a “short esophagus” is also untrue.

Paraesophageal HH: The Paraesophageal HH: The IssuesIssues

Anatomy.Anatomy. Natural history.Natural history. Symptoms and syndromes.Symptoms and syndromes. Indications for operation.Indications for operation. The operation:The operation:

– How often is there a short esophagusHow often is there a short esophagus– How to deal with the sacHow to deal with the sac– How should we close the hiatal openingHow should we close the hiatal opening– Should a fundoplication be includedShould a fundoplication be included– Prevention of reherniationPrevention of reherniation

Natural HistoryNatural History Textbooks in the past tended to follow Textbooks in the past tended to follow

Ronald Belsey, who in the early 1980’s Ronald Belsey, who in the early 1980’s claimed that 25% of untreated pts. with claimed that 25% of untreated pts. with paraesophageal HH would end up with paraesophageal HH would end up with incarceration and serious complications. incarceration and serious complications.

For awhile standard practice was to For awhile standard practice was to recommend prophylactic repair.recommend prophylactic repair.

Experience, however, led to a pull back: Experience, however, led to a pull back: the predicted disasters weren’t evident.the predicted disasters weren’t evident.

Paraesophageal Hernias: Operation or Observation? Stylopoulos N, Rattner D. Ann Surg 2002;236:492.

WW compared with ELHR using all data available in the literature.

Mortality rate of ELHRMortality rate of ELHR 1.4%1.4%

Chances of Sx with WWChances of Sx with WW 1.1%/y1.1%/y

ELHR vs WW (pts >65)ELHR vs WW (pts >65) Decrease 0.13 Decrease 0.13 QALYsQALYs

ELHR would be more beneficial than WW in less than one in five patients. In other words, an operation is not indicated for asymptomatic or minimally symptomatic patients.

Paraesophageal HH: The Paraesophageal HH: The IssuesIssues

Anatomy.Anatomy. Natural history.Natural history. Symptoms and syndromes.Symptoms and syndromes. Indications for operation.Indications for operation. The operation:The operation:

– How often is there a short esophagusHow often is there a short esophagus– How to deal with the sacHow to deal with the sac– How should we close the hiatal openingHow should we close the hiatal opening– Should a fundoplication be includedShould a fundoplication be included– Prevention of reherniationPrevention of reherniation

Clinical ManifestationsClinical Manifestations

Reflux: heartburn, regurgitation, Reflux: heartburn, regurgitation, coughing, etc.coughing, etc.

Entrapment: pain; perforation (rare).Entrapment: pain; perforation (rare). Obstructive: dysphagia; bleeding Obstructive: dysphagia; bleeding

from gastric stasis; dyspnea.from gastric stasis; dyspnea.

In the face of symptoms, we often do not order pH monitoring, because surgery is indicated anyway, a fundoplication is routine, and the test is often unreliable because the esophagus and stomach are distorted.

Paraesophageal HH: The Paraesophageal HH: The IssuesIssues

Anatomy.Anatomy. Natural history.Natural history. Symptoms and syndromes.Symptoms and syndromes. Indications for operation.Indications for operation. The operation:The operation:

– How often is there a short esophagusHow often is there a short esophagus– How to deal with the sacHow to deal with the sac– How should we close the hiatal openingHow should we close the hiatal opening– Should a fundoplication be includedShould a fundoplication be included– Prevention of reherniationPrevention of reherniation

UCSF Experience: PEHUCSF Experience: PEH

Total patients: lap repair Total patients: lap repair of PEHof PEH

105 patients105 patients

AgeAge 69 years69 years

WomenWomen 48%48%

Late follow-up (pts Late follow-up (pts located)located)

67 patients67 patients

1993-2002

360360° wrap° wrap 42 (63%)42 (63%)

240240° wrap° wrap 24 (36%)24 (36%)

Ant gastropexyAnt gastropexy 11

ResultsResults

Late UGI series 57 patients (77%) Two wraps axial slip

Two wraps small PEH

Reoperation 6 patients (9%) Esophageal perf: one

Erosion of mesh: one

Reflux: 4, all partial wraps

ResultsResults

Late UGI series 57 patients (77%) Two wraps axial slip

Two wraps small PEH

Reoperation 6 patients (9%) Esophageal perf: one

Erosion of mesh: one

Reflux: 4, all partial wraps

None of these fourhad reflux or other sx

None of these fourhad hernias

Comparison of Mesh vs No Comparison of Mesh vs No Mesh RepairMesh Repair

Nineteen articles 1368 patients

Johnson JM, et al. Surg Endosc 2006;20:362

729 No Mesh729 No Mesh 78 (11%)78 (11%)

639 Mesh639 Mesh 12 (2%)12 (2%)

Operations Recurrences

Randomized Mesh TrialRandomized Mesh TrialBiologic Prosthesis Reduces Recurrence After Laparoscopic Paraesophageal Hernia Repair. B.K. Oelschlager, et al. Ann Surg 2006;244:481.

No. Pts. % Recurrence

Mesh 4 9%

No mesh 12 24%

99 patients randomized to primary repair, with or without biologic (SIS) mesh. These are the 6 month followup data on hernia recurrence. No reoperations.

The premise that the collagen mesh will permanently increase the strength of the repair is untested and implausible. The primary operation was not standardized. The experience of the surgeons was not stated. How many surgeons was not stated. Relationship of recurrence to surgeon was not given. What was actually done (the various techniques; Nissen or no; etc) was not reported. The operations were not videorecorded.

Elements of the OperationElements of the Operation Detach the sac from Detach the sac from

the stomach the stomach circumferentially.circumferentially.

Excise any sack Excise any sack remnants attached to remnants attached to the stomach or GEJ.the stomach or GEJ.

Mobilize the lower Mobilize the lower esophagus.esophagus.

Close the hiatus with or Close the hiatus with or without mesh. Use the without mesh. Use the capstan jamming knot capstan jamming knot to make it easy.to make it easy.

Nissen fundoplication.Nissen fundoplication. Posterior gastropexy Posterior gastropexy

and collar anchoring and collar anchoring stitches for the stitches for the plication. plication.

No anterior No anterior gastropexy or gastropexy or gastrostomy in gastrostomy in primary repairs.primary repairs.

Sack Attack

Patient #2: 63 y.o. manPatient #2: 63 y.o. manLarge HH known for 30 y. Now has dyspnea, heartburn, and chronic abd pain. The dyspnea is getting worse. Radiographs show that the stomach is in the chest adjacent to the ribs in the right mid-axillary line, and the transverse colon is in the chest adjacent to the ribs in the left mid-axillary line.

In addition to the stomach & transverse colon, the pancreas was also in the chest.

Abdominal viscera in the chest

Patient #3: 72 y.o. manPatient #3: 72 y.o. man

Two previous mesh repairs for a paraesophageal hiatal hernia, 8/06 and 3/07. Now has abdominal pain and inability to swallow. UGI series shows recurrent paraesophageal hiatal hernia.

Anterior Nissen GastropexyAnterior Nissen GastropexyFor Paraesophageal HHFor Paraesophageal HH

The axis of one line of sutures keeps the gastroesophageal junction in the abdomen. The axis of the second line prevents the greater curvature from rotating on the first line or the GE junction, thereby offsetting any tendency of the fundus to return to the chest.

The sutures attach the anterior surface of the stomach to the diaphragm and posterior rectus sheath.

This is it, if you really need to use a gastropexy for this condition.

GastropexyGastropexy Most pexy operations for abdominal Most pexy operations for abdominal

viscera fail in the long run. Don’t viscera fail in the long run. Don’t trust intuition. Results contradict.trust intuition. Results contradict.

Gastropexy, cecopexy, Gastropexy, cecopexy, sigmoidopexy, and nephropexy sigmoidopexy, and nephropexy return to their original unwanted return to their original unwanted orientations. Adding a gastrostomy orientations. Adding a gastrostomy doesn’t secure a gastropexy: the doesn’t secure a gastropexy: the stomach still pulls away.stomach still pulls away.Posterior gastropexy is the

only pexy that predictably works.

GastropexyGastropexy

Thus, anterior gastropexy was largely Thus, anterior gastropexy was largely abandoned as a primary operation for abandoned as a primary operation for paraesophageal hernias by 1990.paraesophageal hernias by 1990.

The principal remaining use is as an The principal remaining use is as an emergency measure in bad risk emergency measure in bad risk patients.patients.

Follow Nissen’s method, however. One Follow Nissen’s method, however. One or two stitches plus a gastrostomy is or two stitches plus a gastrostomy is not enough.not enough.

ConclusionsConclusions There is no difference between Type II & Type III There is no difference between Type II & Type III

hernias. There is a continuous spectrum.hernias. There is a continuous spectrum. Surgery is indicated only for symptoms.Surgery is indicated only for symptoms. The sac must be completely separated from the The sac must be completely separated from the

stomach and trimmed, but not “entirely excised.”stomach and trimmed, but not “entirely excised.” Fundoplication routine.Fundoplication routine. A 360A 360° wrap cures the reflux in most patients.° wrap cures the reflux in most patients. Mesh may or may not be used, but is not Mesh may or may not be used, but is not

important in most cases.important in most cases. Anterior gastropexy must be done right.Anterior gastropexy must be done right.