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Purpose: Review current concepts of PEH
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1. Current Concepts With Paraesophageal Hernia P.A. Seshadri M.D., FRCSC
October 2001
2. Purpose: Review current concepts of PEH…… Background
Management
Laparoscopy
Technique
Controversial Issues
Video presentation
3. Conclude: Laparoscopic repair of PEH is …. Difficult
Technically feasible, safe, effective
Advantages over open repair
However……….
4. PO Buenaventura, Semin Thorac Cardiovasc Surg 2000
5. Paraesophageal Hernia: Types Most (95%) are Type I
PEH account for only 5-10% of all hiatal hernias
Of PEH 95% are combined Type III
Overall published recurrence rates are ~ 15% - important wrt esophageal shortening- important wrt esophageal shortening
6. Management problem because: Surgeons cannot agree
- preoperative evaluation
- to operate or not to operate
- which operation and how
- appropriate follow-up
10. Surgery is technically challenging…. Safe dissection of anatomically abnormal hiatus
Dealing with a shortened esophagus
Management of large diaphragmatic defect
11. Preoperative CXR
12. Upper GI: Organoaxial volvulus
14. Presentation is variable
from asymptomatic to severe postprandial pain with inability to vomit and failure to pass an NG tube
Most common reasons prompting evaluation in those with type III hernias is
Postprandial distress
Aneamia
Obstructive symptomsPresentation is variable
from asymptomatic to severe postprandial pain with inability to vomit and failure to pass an NG tube
Most common reasons prompting evaluation in those with type III hernias is
Postprandial distress
Aneamia
Obstructive symptoms
15. Preoperative evaluation: CXR
Barium swallow
- define anatomic relationships, esophageal length, volvulus
UGI endsocopy
- evaluation of herniated stomach (ulcers, ischemia…)
Manometry/ pH
- ? Tailor type of fundoplication
- 5% not able to pass catheter
- 35% not reliable d/t external compression
Barium enema
- assess contributing factors for anemia
16. Should we operate? Skinner and Belsey (1967)
- nonoperative observation of 21 minimally symptomatic patients
- 26% died of catastrophic complications
Treacy and Jamieson (1987)
- monitored 24 patients
- elective surgery eventually in 13 (54%) because of progressive symptoms
-none needed emergency surgery
Haas (1990)
- 21 patients intrathoracic volvulus (8 asymptomatic)
-10 required emergency surgery
17. Surgical Issues/ Principles: Transabdominal vs. transthoracic approach
Open vs laparoscopic approach
Reduction of hernia contents
Excision of hernial sac
Dealing with shortened esophagus
Repair of diaphragm
Addition of antireflux procedure
Intraabdominal fixation of stomach
Transthoracic – good for complete excision of sac and full esophageal mobilization
Transabdominal – facilitates reduction of volvulusTransthoracic – good for complete excision of sac and full esophageal mobilization
Transabdominal – facilitates reduction of volvulus
18. Laparoscopic challenges: Experience
Hernia contents/volvulus make identification of anatomy difficult
Dissection of large sac ? bleeding ? poor visualization
++ redundant tissue at GEJ makes fundoplication difficult
19. Lithotomy position Large angle at hips to allow for instruments to move easily
Support with bean-bag or tape to facilitate steep Fowler position
20. Port placement
21. Reduction of hernial contents
22. Atraumatic graspers
Take care while reducing hernial contents b/c stomach wall may be ischemic/atrophic and prone to perforation
Experienced assistant providing retraction Reduction of hernial contents
23. N Basso et al. Surg Laparosc Endosc 9:257-262, 1999 Dissect sac on a curved line from left to right
Dissect left first because left gastric artery may be stretched and distorted
24. Hiatal defect
25. Esophageal Hiatus
26. Esophageal Hiatus Lighted bougie facilitates esophageal identification
Endoscopy helps find the GEJ
Need complete circumferential dissection of hiatus to promote closure and esophageal length
Leave fascia/parietal peritoneum overlying crura
Beware vagus nerves
Change visual field often to give perspective
27. The shortened Esophagus: < 2.5 cm of intraabdominal esophagus without tension
Poor preoperative prediction but suspect if….
Large hiatal hernia
Esophageal stricture
Barrett’s esophagus
Reoperative surgery
LES < 35 cm from incisors
28. Dealing with short esophagus: Excise GEJ redundant tissue
Mobilize mediastinal esophagus circumferentially as high as possible
A few cm gained by anterior displacement of esophagus with posterior diaphragm repair
Lengthening procedure required in 5-20%
Nissen-collis
29. LL Swanstrom et al. Arch Surg 133:869, 1998
32. Diaphragmatic defect: Nonabsorbable suture
Simple closure
Pledgets
Mesh / PTFE
Mesh over relaxing incision
35. Alternatively Mesh can be used to close very large defects
37. Mesh repair
39. Fundoplication: Most perform one
50% have a preop history of GERD
Preop evaluation of GERD unreliable
20-30% will reflux postoperatively
Circumferential dissection of GEJ disrupts natural antireflux mechanisms
Facilitates intraabdominal anchor - recent article on gastropexy showed 23% recurrence- recent article on gastropexy showed 23% recurrence
40. Fundoplication: Anchor wrap to diaphragm
Gastopexy not required
Chest tube not needed
Closed suction drain into chest/mediastinum
41. Results of Laparoscopic Repair PEH
42. PO Buenaventura, Semin Thorac Cardiovasc Surg 2000
43. Laparoscopic Repair of Giant Paraesophageal Hernia: 100 Consecutive Cases James Luketich et al. Ann Surg 232, 2000
1995 – 2000 (retrospective)
100 patients with laparoscopic repair (1/3 stomach in chest)
72 Nissen, 27 Nissen-Collis
3 conversions
1 death at 5 months d/t stroke
44. Laparoscopic Repair of Giant Paraesophageal Hernia: 100 Consecutive Cases Median LOS = 2 days
Median F/U = 12 months
1 reoperation for recurrence
10 patients on PPI
45. Comparison of Laparoscopic versus Open Repair of Paraesophageal Hernia Phillip Schauer et al. Am J Surg 176, 1998
1990 –1998 (retrospective)
Symptomatic PEH with acceptable OR risk
25 Open (chest, abdo) and 67 Laparoscopic
OR time:
Laparoscopic = 264 min
Open = 208 min
OR time decreased to 214 in last 15 cases
48. Laparoscopic Repair of Large Type III Hiatal Hernia: Objective Follow-up Reveals High Recurrence Rate Majid Hashemi et al. J Am Coll Surg 190, 2000
1985 - 1998
54 patients (13 laparotomy, 14 thoracotomy, 27 laparoscopy)
All had antireflux operation
Median of 24 months 94% answered questionnaire
75% had videoesophagram by one radiologist
50. Symptomatic Success
- Laparoscopic 76%
- Open 88%
Recurrence (any herniation stomach above diaph)
- Laparoscopic 9/21 (42%)
- Open 3/20 (15%)
7/12 (58%) of recurrences were asymptomatic
51. Problems: Includes laparoscopic learning curve
No pledgets
Hernia sac removed via open approach and dissected but left laparoscopically
Wide confidence intervals
Only one Collis
Still no RCT or prospective evaluation with standardized operation and follow-up
52. Conclusion: Management of PEH challenging
Operative principles
Reduce hernial contents
Excise sac
Repair diaphragm without tension
Simlpe sutures ? pledgets ? Mesh
Fundoplication
53. Laparoscopic repair is safe and effective but require….. Experience (experienced assistant)
May have to deal with shortened esophagus
Remove GEJ fat pad
With laparoscopy we are also learning how to perform the open procedure better
Moving target
Need more long term, well organized studies
54. Thank you
55. Presentation is variable
from asymptomatic to severe postprandial pain with inability to vomit and failure to pass an NG tube
Most common reasons prompting evaluation in those with type III hernias is
Postprandial distress
Aneamia
Obstructive symptomsPresentation is variable
from asymptomatic to severe postprandial pain with inability to vomit and failure to pass an NG tube
Most common reasons prompting evaluation in those with type III hernias is
Postprandial distress
Aneamia
Obstructive symptoms
56. Previous small wrap
57. Previous wrap divided with a stapler