laparoscopic repair of hiatal hernias · conclusions • laparoscopic repair of paraesophageal...
TRANSCRIPT
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Laparoscopic Repair of Hiatal
Hernias
Paraesophageal
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Benny Weksler, MD
Chief, Division of Thoracic SurgeryEastridge-Cole Professor of Thoracic OncologyUniversity of Tennessee Health Science CenterMemphis TN
[email protected] +1-901-448-2918
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I have no financial relationships to disclose
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Not all hiatal hernias are the same!
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Type I Type II/III Type IVPatulous Cardia
Adapted from Landreneau RD, lecture on Hiatal Hernia, 2008
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Symptoms• GERD/Regurgitation - 66%
• Chest or abdominal pain - 54%
• Dysphagia 43%
• Dyspnea - 42%
• Anemia - 41%
• Bloating - 31%
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Indications for Surgery
• Symptomatic patients
• Role for prophylactic repair?
Older studies suggested 24%-30% incidence of complications (Skinner 1967, Hill 1968)
More recent studies suggest complication rate of 1%/year
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Operative Steps
Figure: copyright University of Pittsburgh Medical Center
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Reduction of the Hernia Sac
• Video
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Dissection of the sac and esophageal mobilization
• Video
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Short gastric vessels and Left Crux
• Video
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To Wrap or not to Wrap?
• Recognizing short esophagus
• Symptoms
• Older patients requiring Collis gastropalsty
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I Do Not Wrap:
• Patients without GERD or regurgitation
• Older patients with short esophagus
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Gastropexy:
Requires full esophageal
mobilization!
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Gastropexy
• Video
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Traditional Wrap
• Dissection of the gastroesophageal fat pad
• Nissen or Tupet fundoplication
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Wrap
• Video
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Cruroplasty:
Mesh or no Mesh?
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Hernia recurrence with mesh - 9%
Hernia recurrence with primary repair - 24%
Oelschlager et al, Annal of Surg 2006, 244:481-490
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Oelschlager, J Am Coll Surg 2011, 214:461-468
Hernia recurrence with primary repair - 59%
Hernia recurrence with mesh - 54%
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Use of Mesh
• Cruroplasty under tension
• No crural integrity (“beaten up crux”)
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Crural Closure
• Video
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Results
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• Gold standard
• Median follow-up 72 months
• 2.1% (2/94) patients required re-operation for recurrence
• 92.5% (87/94) patients with good or excellent results
Maziak et al, JTCVS 1998, 115:53-62
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89%
• Median follow-up 30 months
• 3.2% of patients required re-operation for recurrence
• 89% of patients with symptomatic relief
• 15.7% of radiologic recurrence
Luketich et al, JTCVS 2010, 139:395-404
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Conclusions
• Laparoscopic repair of paraesophageal hernia can be performed safely and with good results
• Operative experience and attention to dissection of the sac, esophageal mobilization, and maintenance of crural integrity are determinants of good surgical outcomes
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Thank You!