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Open Paraesophageal Hernia Repair
Hiatal hernia (HH) was first recognized more than 400 years ago. In 1610 Ambrose Paré described a patient with the stomach herniating through the esophageal hiatus. Bowditch was the first to report repair of an HH in 1853, and Akerlund first reported paraesophageal herniation in 1926. In 1945 Harrington described the first series of patients who underwent HH repair. In 1951 Allison was the first to attribute the symptoms of gastroesophageal reflux disease (GERD) and acid ingestion to an HH and also described an anatomic repair. In 1968 Hill and Tobias were the first to clearly understand the anatomy (gastroesophageal junction [GEJ] and stomach) and clinical implications of paraesophageal hernias (PEHs).
HHs were first classified into three types by the Swedish radiologist, Ake Akerlund. The current classification scheme defines four types of hiatal or PEHs. The four types are classified based on the location of the GEJ and the fundus of the stomach in relationship to the diagrammatic crura (hiatus). Type I (sliding) hernia is when the GEJ migrates into the chest only, type II (true) is when the GEJ remains in the abdomen and the fundus of the stomach herniates into the chest, type III (mixed) is the combination of type I and II with herniation of both the GEJ and fundus into the chest, and type IV (complex) is when other abdominal viscera (colon [ Fig. 27.1 ], small bowel, spleen, pancreas, or omentum) migrate into the chest with the GEJ and/or stomach. Type I, or sliding hernias, are the most common type and account for approximately 95% of all HHs, with the remaining three types (PEHs) making up the remaining 5% of HHs; 90% of the PEHs are the type III mixed PEHs ( Fig. 27.2 ), and the rarest (<5%) are the type II true PEHs.
Type IV complex paraesophageal hernia (PEH) (colon). Barium enema of a patient with type IV PEH showing transverse colon that has passed through dilated hiatus into the hernia sac within the left chest.
Large type III paraesophageal hernia (PEH). Schematic of a type III PEH demonstrating both the gastroesophageal junction and fundus of stomach above the normal positioned diaphragmatic hiatus.
(Used with permission of Mayo Foundation for Medical Education and Research. All rights are reserved.)
An HH is characterized by enlargement of the opening between the diaphragmatic crura, which allows the stomach and other abdominal viscera to elevate into the chest. The cause of enlargement of the hiatus is related to increased intraabdominal pressure creating a transdiaphragmatic pressure gradient between the thoracic and abdominal cavities at the GEJ. This pressure gradient results in weakness of the phrenoesophageal membrane and widening of the esophageal hiatus. Conditions that cause an increase in intraabdominal pressure include obesity, pregnancy, chronic constipation, chronic obstructive pulmonary disease (COPD) with chronic coughing, and strenuous jobs with significant amount of lifting. Aging is also a significant risk factor for development of PEH. PEH mainly affects older adults, with the median age of presentation between 65 and 75 years of age. The US population, older than 65 years of age, increased from 13% to 17% between 2000 and 2015 and is predicted to increase to 24% by 2060. With this increase in the elderly population and the rise of obesity within the United States, the incidence of patients with PEH that will require surgical care will increase significantly over time, so timing of surgical correction and what approach and repair is paramount to decrease operative morbidity and mortality and to improve short- and long-term outcomes.
Indication for Surgical Repair
Surgical repair is indicated in patients with symptomatic or complications of PEHs, the timing of which depends upon the acuity of presentation and significance of symptoms. Emergency repair is required in patients with acute gastric volvulus ( Fig. 27.3 ), uncontrolled gastrointestinal bleeding, obstruction, strangulation, perforation, or irreversible respiratory comprise secondary to the PEH. As expected a patient with a PEH that presents as an emergency and requires surgical correction is associated with higher mortality rates. Elective repair is recommended in patients with PEH who experience chronic symptoms that are increasing in frequency and severity, such as GERD refractory to medical therapy, dysphagia, early satiety, postprandial chest or abdominal pain, postprandial shortness of breath, aspiration, chronic anemia (Cameron erosions), or vomiting. Surgical repair of these patients electively is associated with improved symptoms and better quality of life (QoL). Prophylactic PEH repair (PEHR) in asymptomatic patients is controversial. There is no consensus, but traditionally most surgeons feel that the very old or debilitated patients should not undergo surgery, whereas younger and healthier patients with life expectancy of 5 to 10 years should consider surgery to prevent both risk of acute gastric volvulus, especially if greater than 50% of stomach in the chest, and potentially progressive symptoms. In a recent study, the mortality rate from elective repair was estimated to be 1.4%, while the probability of developing acute symptoms that would necessitate emergency surgery was 1.1%. Allen and colleagues followed 23 patients with large PEHs who refused surgery and preferred medical management, for a median of 78 months (range, 12 to 268 months). In four patients, progressive symptoms developed, and one patient died from aspiration. They concluded that patients with an intrathoracic upside-down stomach who have obstructive symptoms at initial presentation should undergo repair and that elective operation is safe and effective. However, gastric strangulation is extremely rare. The lifetime risk of developing acute symptoms requiring emergency surgery decreases exponentially with age older than 65 years.
Preoperative Evaluation
Detailed history, physical exam, and endoscopic and radiographic evaluation are warranted in patients with PEHs to maximize the best surgical treatment, approach, and type of procedure for symptomatic and asymptomatic PEH patients. Current symptoms, previous medical therapies, comorbidities, and operative reports are recorded. All patients undergo upper endoscopy, barium swallow/upper gastrointestinal (UGI) series, computed tomography (CT) scan of chest and upper abdomen, and review of pathology biopsies if performed. Upper endoscopy is performed prior to surgery in an elective situation or at the time of emergency surgery to evaluate the hernia, including retroflexion maneuver, and to rule out possible esophageal or gastric pathology. In addition, a gastric volvulus can be determined, as well as mucosal ischemia or perforation related to strangulation. Oral contrast studies provide important information of gastric anatomy but most importantly length of the esophagus. Esophageal manometry and pH analysis are not required because they are unreliable and difficult to perform. Review of previous operative reports is paramount for success if you are performing a redo procedure. Attention should focus on type of crura repair, if mesh was used and how it was anchored, type of fundoplication, if the hernia sac was removed, if a gastroplasty or esophageal lengthening procedure was performed, and if an abdominal incisional hernia was repaired and if mesh was used for the repair.
Operative Approaches
PEHs can be repaired transabdominally or transthoracically. Transabdominal repairs can be performed open or laparoscopically. In most practices currently in the United States, laparoscopic PEHR is preferred for most patients in both elective and emergency situations. The first report of laparoscopic HH repair was published by Cuschieri and colleagues in 1992. Even in the earliest of series, laparoscopic PEHR was associated with less morbidity compared with the open repair. The enthusiasm of laparoscopic community was dampened in 2000 when Hashemi and colleagues demonstrate a 42% recurrence rate for the laparoscopic approach as opposed to 15% for the open approach. Open transabdominal approach is used in patients who have had a limited number of upper abdominal procedures in the past, and reserve the transthoracic approach for patients who have failed previous transabdominal procedures, a history of abdominal wall mesh, history of abdominal abscess, infection, and contamination, and significant elevated body mass index (BMI) (>40). The three operative approaches have not been compared with one another in randomized trials, and the optimal operative approach for PEHR remains controversial and varies most depending on surgeon training and experience.
In an analysis of approximately 40,000 patients from 1999 through 2008 from the Nationwide Inpatient Sample (NIS) database, 74%, 17%, and 9% were performed open transabdominally, transthoracically, and laparoscopically, respectively. Currently, laparoscopic PEHR has surpassed open transabdominal repair as the most commonly performed procedure for PEHs. In the NIS study, transthoracic approach was associated with the longest hospital stay (7.8 days), the greatest need for mechanical ventilation (5.6%), and the greatest risk of having pulmonary embolism. Laparoscopic approach was associated with the shortest hospital stay (4.5 days) and the lowest risk of requiring mechanical ventilation (2.3%). In a second study using the NIS database, published in 2017, 63,800 patients were analyzed from 2000 through 2013 to assess the effect of minimally invasive PEH surgery (MIS PEH) on patient outcomes. Abdominal approach was used in 94.2% of patients (67.1% laparoscopically and 32.9% open) and 5.8% via the thoracic approach (24.5% thoracoscopically and 75.5% open). Patients undergoing MIS PEH experienced shorter hospital stay and decreased overall cost. Long-term outcome data are not known in these NIS studies. Other uncontrolled studies suggest that morbidity and mortality rates appear lower for laparoscopic PEHR compared with the other approaches. Although the risk of radiographic recurrence is higher with laparoscopic approach, reoperation rates are similar.
Transabdominal Repair
An open or laparoscopic PEHR involves the same sequence of steps and principles of repair. An open transabdominal incision is usually performed via an upper abdominal incision from the xiphoid to just above the umbilicus. At times to facilitate further hiatal exposure the upper portion of the incision is extended to the left of the xiphoid. An upper hand retractor is preferred, which is connected to the bed bilaterally and is used instead of circumferential incisional retractor to allow elevation of the foregut for maximal exposure of the hiatal anatomy. Sequence of open surgical steps will now be described in detail.
Dissection of Hiatus
To prevent reherniation after PEHR, complete dissection and removal of the hernia sac from the mediastinum is mandatory. This dissection should be performed meticulously to avoid injury to mediastinal pleural, pericardium, aorta, and vagal nerves. If a pneumothorax occurs, it is not a hemodynamic issue during an open approach and a chest tube is placed laterally above the diaphragm at completion of the repair prior to closure. The peritoneal covering of the crus on the abdominal side is preserved when dividing the gastrohepatic omentum from the right crus of the diaphragm to improve stability of the hiatus tightening. A Penrose drain is used and placed around the esophagus at the GEJ to elevate the esophagus and stomach to improve dissection of the posterior hiatus. Short gastric vessels are divided with an energy device (bipolar) to allow complete mobilization of the stomach into a normal configuration and for facilitation of the planned fundoplication.
Esophageal Mobilization
Distal mobilization of the esophagus and GEJ into the abdomen with sufficient length (4 to 5 cm) of intraabdominal esophagus is essential for a tension-free PEHR and reduction of recurrence. Energy-assisted intrathoracic dissection is warranted to prevent injury to associated anatomic structures and more importantly to minimize the injury to the vagus nerves. This dissection is usually carried up to the level of the aortic arch to allow for a tension-free esophagus. If adequate intraabdominal esophagus cannot be achieved, a lengthening procedure is required; a true shortened esophagus is rare, usually less than 5% of patients. Chronicity of the PEH may lead to a higher incidence of a shortened esophagus. Lengthening of the esophagus is performed by a Collis gastroplasty. The Collis procedure creates a gastric tube by vertically stapling the proximal stomach from the angle of His, parallel to a large bougie, 48 to 51 French, positioned along the lesser curvature of the stomach ( Fig. 27.4 ). The neoesophagus is an elongated gastric tube, thus creating an extension of the esophagus that allows for the new esophagogastric junction to be greater than 4 cm in the abdomen. The Collis procedure was originally performed via a left thoracotomy, but more recently it has been performed transabdominally via open approach or laparoscopically. The open or laparoscopic technique is called a wedge Collis gastroplasty because a wedge of fundus is resected to allow for vertical placement of the endoscopic stapler parallel to the lesser curvature, thus creating an elongated intraabdominal esophagus ( Fig. 27.5 ).
Closure of Hiatus
After complete mobilization of the esophagus, the crura of the diaphragm are closed posteriorly to the esophagus. The closure of the hiatal defect is one of the most crucial steps in repair of a PEH. The repair must be tension free. The repair can be performed primarily, with a patch only, or a combination of primary repair and patch reinforcement. Primary closure is usually performed with nonabsorbable sutures, usually 3 to 5, depending on the size of hiatal defect, in an interrupted fashion; some surgeons prefer pledgeted horizontal mattress sutures because the cura have no fascial layer. If the crural fibers are disrupted during the dissection or the primary repair is under tension, the crural closure can be reinforced with biologic mesh, such as porcine dermal matrix or bovine pericardium. In addition, new bioresorbable materials are being evaluated and may prove useful at the hiatus to help reduce hernia recurrence. Synthetic permanent material such as polytetrafluoroethylene (PTFE) or polypropylene (Prolene) mesh is contraindicated for reinforcement or primary repair of hiatal defect because of serious and even life-threatening complications, including esophageal erosion with ulceration and perforation as well as abscess formation.
Reinforcement of a hiatal closure at the time of PEHR has been shown to reduce recurrence and reoperations. In a 2016 meta-analysis of four randomized trials including 406 patients, compared with suture closure, mesh reinforcement of the hiatal closure reduced reoperations 2% versus 9% and recurrences 16% versus 27%, but not the complication rate of 10% for both, respectively. Only the reoperation rate was statistically significant. In our practice, we selectively use mesh reinforcement during PEHR. When we reinforce, we usually use bovine pericardium in older patients, especially women greater than 80 years of age, steroid-dependent patients, reoperations, and significant COPD patients. The complication rate related to mesh reinforcement is related to the type of mesh and the configuration used. Biologic and bioresorbable mesh complications are usually only dysphagia as compared with erosion, perforation, stenosis, fibrosis, and the need for complex reoperations because of synthetic nonabsorbable mesh ( Fig. 27.6 ).
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