Hiatus hernia surgery
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]
Overview
Surgery is the mainstay of treatment for patients with a symptoms or complications. Paraesophageal hernias can be repaired transabdominally or transthoracically. Laparoscopic approach is preferred for most patients. A Nissen-fundoplication is usually done with the surgery. Overall mortality and morbidity rates associated with laparoscopic paraesophageal hernia repair are low. A fixation of the stomach to the abdominal wall (anterior gastropexy) can be used to reduce the risk of gastric reherniation into the thoracic cavity. Complications include pneumonia, pulmonary embolism, heart failure, postoperative leak, and recurrence.
Surgery
- Surgery is the mainstay of treatment for patients with a symptoms or complications.[1]
- Emergency repair is required for:[2]
- Patients with uncontrolled bleeding
- Patients with obstruction, strangulation, or perforation
- Patients with acute gastric volvulus
- Paraesophageal hernias may be repaired transabdominally or transthoracically.
- Transabdominal repairs may be performed by open laprotomy or laparoscopically.
- Laparoscopic approach is preferred for most patients.
- Open transabdominal approach is used in patients with multiple upper abdominal surgeries in the past.[3]
- Transthoracic repair was associated with the longest hospital stay, the greatest need for mechanical ventilation (5.6 percent of patients), and the greatest risk of having a pulmonary embolism.[4]
- Sufficient mobilization of the lower esophagus in the mediastinum is done. The esophagus must be mobilized to the level of the aortic arch or until ≥4 cm of intra-abdominal esophagus has been freed without tension.[5]
- The crura of the diaphragm are closed inferiorly and posteriorly to the esophagus.
- A Nissen-fundoplication is usually done with the surgery.
- The recurrence rate is high because of a pressure gradient resulting from the positive intra-abdominal pressure and negative intrathoracic pressure.
- A fixation of the stomach to the abdominal wall (anterior gastropexy) can be used to reduce the risk of gastric reherniation into the thoracic cavity.
- A barium swallow study is done on the first postoperative day to assess for possible esophageal leak and early hernia recurrence and to evaluate gastric emptying and motility.
- Overall mortality and morbidity rates associated with laparoscopic paraesophageal hernia repair are low.
Complications
Complications of gastric surgery include:[6]
- Pneumonia
- Pulmonary embolism
- Heart failure
- Postoperative leak
- Recurrence: The rate of radiographic recurrence (assessed by a video barium esophagram) is higher than that of clinical recurrence.
- Most patients with a radiographic recurrence after PEHR are asymptomatic, and patients with a clinical recurrence often have symptoms that can be controlled with medications.
- Only a small fraction of patients will require a re-repair for complications or intractable symptoms.
- The mortality and morbidity rates are higher in patients who are ≥70 years of age and those who require emergency surgery.
Video shows hiatus hernia repair
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References
- ↑ Kohn GP, Price RR, DeMeester SR, Zehetner J, Muensterer OJ, Awad Z; et al. (2013). "Guidelines for the management of hiatal hernia". Surg Endosc. 27 (12): 4409–28. doi:10.1007/s00464-013-3173-3. PMID 24018762.
- ↑ Markar SR, Mackenzie H, Huddy JR, Jamel S, Askari A, Faiz O; et al. (2016). "Practice Patterns and Outcomes After Hospital Admission With Acute Para-esophageal Hernia in England". Ann Surg. 264 (5): 854–861. doi:10.1097/SLA.0000000000001877. PMID 27355264.
- ↑ Hashemi M, Peters JH, DeMeester TR, Huprich JE, Quek M, Hagen JA; et al. (2000). "Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate". J Am Coll Surg. 190 (5): 553–60, discussion 560-1. PMID 10801022.
- ↑ Paul S, Nasar A, Port JL, Lee PC, Stiles BC, Nguyen AB; et al. (2012). "Comparative analysis of diaphragmatic hernia repair outcomes using the nationwide inpatient sample database". Arch Surg. 147 (7): 607–12. doi:10.1001/archsurg.2012.127. PMID 22430093.
- ↑ Larusson HJ, Zingg U, Hahnloser D, Delport K, Seifert B, Oertli D (2009). "Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score and operation type influence morbidity". World J Surg. 33 (5): 980–5. doi:10.1007/s00268-009-9958-9. PMID 19277773.
- ↑ Luketich JD, Nason KS, Christie NA, Pennathur A, Jobe BA, Landreneau RJ; et al. (2010). "Outcomes after a decade of laparoscopic giant paraesophageal hernia repair". J Thorac Cardiovasc Surg. 139 (2): 395–404, 404.e1. doi:10.1016/j.jtcvs.2009.10.005. PMC 2813424. PMID 20004917.