Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach

Background: Once paraesophageal hernia has been diagnosed, it should be repaired immediately because of life-threatening complications such as bleeding, ischemia, and perforation when intrathoracic strangulation or volvulus occurs. We describe our surgical strategy for treating this rare type of hiatal hernia with regard to early and late postoperative complications. Study Design: This was a retrospective case series from a university hospital. Twelve patients (seven women and five men) with a mean age of 64 years (range, 50-76 years) and a completely intrathoracic stomach underwent laparoscopic paraesophageal hernia repair. Seven patients had a type 2 hernia, and five patients had a type 3 hernia. Additional organoaxial volvulus was present in three patients. All patients underwent reduction of the stomach and the greater omentum, excision of the hernia sac, closure of the hiatal defect, and a floppy Nissen fundoplication. Results: Because of severe adhesions, one patient needed an open stomach reduction (conversion rate, 8%). The mean operating time was 161 minutes (range, 110-200 minutes), blood loss was minimal, and the mean postoperative hospital stay was 6 days (range, 4-7 days). There were no intraoperative complications, but early postoperative complications occurred in three patients (25%; one with dysphagia, 1 reoperation due to organoaxial gastric rotation with gastroduodenal obstruction, and one with deep venous thrombosis). No deaths occurred. Followup in all patients is complete, with a mean followup time of 21 months (range, 3-40 months). The complication rate after longterm followup was 8%, and reflux esophagitis symptoms in one patient were completely relieved by medical therapy. Conclusions: Laparoscopic paraesophageal hernia repair was feasible and safe with low morbidity and mortality rates in this elderly patient group. To achieve good longterm results, standard surgical treatment should include reduction of the stomach, complete excision of the hernia sac, closure of the hiatal defect, floppy Nissen fundoplication, and anterior gastropexy. (J Am Coll Surg 1998;187:231-237. (C) 1998 by the American College of Surgeons)