Hiatus hernia surgery
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Hiatus hernia surgery On the Web |
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American Roentgen Ray Society Images of Hiatus hernia surgery |
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. [9,10]
- Emergency repair is required for:[11]
- Patients with acute gastric volvulus
- Patients with uncontrolled bleeding
- Patients with obstruction, strangulation, or perforation
- Paraesophageal hernias can be repaired transabdominally or transthoracically.
- Transabdominal repairs can be performed open or laparoscopically.
- Laparoscopic is preferred for most patients.
- Open transabdominal approach is used in patients with multiple upper abdominal surgeries in the past. [13-16]
- Transthoracic repair was associated with the longest hospital stay (7.8 days), the greatest need for mechanical ventilation (5.6 percent of patients), and the greatest risk of having a pulmonary embolism [17].
- 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.
- 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 following PEHR 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. [1,41].
Complications [1]
- The reported major complications include:
- Pneumonia
- Pulmonary embolism
- Heart failure
- Postoperative leak
- Recurrence
- The mortality and morbidity rates are higher in patients who are ≥70 years of age and those who require emergency surgery.
- 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.
Surgery
Contraindications
Videos
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