1. Laparoscopic Paraesophageal Hiatal Hernia Repair and Fundoplication Lawrence Way, MD

2. Paraesophageal HH: The Issues Anatomy. Anatomy. Natural history. Natural history. Symptoms and syndromes. Symptoms and syndromes. Indications for operation. Indications for operation. The operation: The operation: –How often is there a short esophagus –How to deal with the sac –How should we close the hiatal opening –Should a fundoplication be included –Prevention of reherniation

3. Patient #1: 69 y.o. woman Heartburn x15 y. PPIs relief. UGI: PEH. No pH monitoring.

4. Types I, II, III, IV: Anatomy I Sliding hiatal hernia II Pure paraesophageal HH; GEJ in the normal position. III, IV Mixed paraesophageal IV is III plus another organ herniated The pocket (sack) develops first to the left of the esophagus, which allows the fundus to herniate first. The sack then enlarges anterior to the esophagus, so the body of the stomach eventually rolls upward (volvulus) as it enters the chest anterior to the fundus and esophagus.

5. Paraesophageal Hiatal Hernia Type II Fundus in the chest; GEJ in the abdomen Type III Fundus and GEJ in the chest Type III Entire stomach and GEJ in the chest. Type III Fundus returns to the abdomen; antrum still in the chest The distinction between II and III is more theoretical than real. Actually, whenever there is a paraesophageal component, the GEJ usually moves cephalad with the fundus (ie, they all are type III). The distinction between these types on radiographs is unreliable. The notion that Type III is commonly associated with a “short esophagus” is also untrue.

6. Paraesophageal HH: The Issues Anatomy. Anatomy. Natural history. Natural history. Symptoms and syndromes. Symptoms and syndromes. Indications for operation. Indications for operation. The operation: The operation: –How often is there a short esophagus –How to deal with the sac –How should we close the hiatal opening –Should a fundoplication be included –Prevention of reherniation

7. Natural History Textbooks in the past tended to follow Ronald Belsey, who in the early 1980’s claimed that 25% of untreated pts. with paraesophageal HH would end up with incarceration and serious complications. Textbooks in the past tended to follow Ronald Belsey, who in the early 1980’s claimed that 25% of untreated pts. with paraesophageal HH would end up with incarceration and serious complications. For awhile standard practice was to recommend prophylactic repair. For awhile standard practice was to recommend prophylactic repair. Experience, however, led to a pull back: the predicted disasters weren’t evident. Experience, however, led to a pull back: the predicted disasters weren’t evident.

8. Paraesophageal Hernias: Operation or Observation? Stylopoulos N, Rattner D. Ann Surg 2002;236:492. WW compared with ELHR using all data available in the literature. Mortality rate of ELHR 1.4% Chances of Sx with WW 1.1%/y ELHR vs WW (pts >65) Decrease 0.13 QALYs ELHR would be more beneficial than WW in less than one in five patients. In other words, an operation is not indicated for asymptomatic or minimally symptomatic patients.

9. Paraesophageal HH: The Issues Anatomy. Anatomy. Natural history. Natural history. Symptoms and syndromes. Symptoms and syndromes. Indications for operation. Indications for operation. The operation: The operation: –How often is there a short esophagus –How to deal with the sac –How should we close the hiatal opening –Should a fundoplication be included –Prevention of reherniation

10. Clinical Manifestations Reflux: heartburn, regurgitation, coughing, etc. Reflux: heartburn, regurgitation, coughing, etc. Entrapment: pain; perforation (rare). Entrapment: pain; perforation (rare). Obstructive: dysphagia; bleeding from gastric stasis; dyspnea. Obstructive: dysphagia; bleeding from gastric stasis; dyspnea. In the face of symptoms, we often do not order pH monitoring, because surgery is indicated anyway, a fundoplication is routine, and the test is often unreliable because the esophagus and stomach are distorted.

11. Paraesophageal HH: The Issues Anatomy. Anatomy. Natural history. Natural history. Symptoms and syndromes. Symptoms and syndromes. Indications for operation. Indications for operation. The operation: The operation: –How often is there a short esophagus –How to deal with the sac –How should we close the hiatal opening –Should a fundoplication be included –Prevention of reherniation

12. UCSF Experience: PEH Total patients: lap repair of PEH 105 patients Age 69 years Women48% Late follow-up (pts located) 67 patients 1993-2002 360° wrap 42 (63%) 240° wrap 24 (36%) Ant gastropexy 1

13. Results Late UGI series57 patients (77%)Two wraps axial slip Two wraps small PEH Reoperation6 patients (9%)Esophageal perf: one Erosion of mesh: one Reflux: 4, all partial wraps

14. Results Late UGI series57 patients (77%)Two wraps axial slip Two wraps small PEH Reoperation6 patients (9%)Esophageal perf: one Erosion of mesh: one Reflux: 4, all partial wraps None of these four had reflux or other sx None of these four had hernias

15. Comparison of Mesh vs No Mesh Repair Nineteen articles1368 patients Johnson JM, et al. Surg Endosc 2006;20:362 729 No Mesh 78 (11%) 639 Mesh 12 (2%) OperationsRecurrences

16. Randomized Mesh Trial Biologic Prosthesis Reduces Recurrence After Laparoscopic Paraesophageal Hernia Repair. B.K. Oelschlager, et al. Ann Surg 2006;244:481. No. Pts.% Recurrence Mesh49% No mesh1224% 99 patients randomized to primary repair, with or without biologic (SIS) mesh. These are the 6 month followup data on hernia recurrence. No reoperations. The premise that the collagen mesh will permanently increase the strength of the repair is untested and implausible. The primary operation was not standardized. The experience of the surgeons was not stated. How many surgeons was not stated. Relationship of recurrence to surgeon was not given. What was actually done (the various techniques; Nissen or no; etc) was not reported. The operations were not videorecorded.

17. Elements of the Operation Detach the sac from the stomach circumferentially. Detach the sac from the stomach circumferentially. Excise any sack remnants attached to the stomach or GEJ. Excise any sack remnants attached to the stomach or GEJ. Mobilize the lower esophagus. Mobilize the lower esophagus. Close the hiatus with or without mesh. Use the capstan jamming knot to make it easy. Close the hiatus with or without mesh. Use the capstan jamming knot to make it easy. Nissen fundoplication. Nissen fundoplication. Posterior gastropexy and collar anchoring stitches for the plication. Posterior gastropexy and collar anchoring stitches for the plication. No anterior gastropexy or gastrostomy in primary repairs. No anterior gastropexy or gastrostomy in primary repairs. Sack Attack

18. Patient #2: 63 y.o. man Large HH known for 30 y. Now has dyspnea, heartburn, and chronic abd pain. The dyspnea is getting worse. Radiographs show that the stomach is in the chest adjacent to the ribs in the right mid-axillary line, and the transverse colon is in the chest adjacent to the ribs in the left mid-axillary line. In addition to the stomach & transverse colon, the pancreas was also in the chest. Abdominal viscera in the chest

19. Patient #3: 72 y.o. man Two previous mesh repairs for a paraesophageal hiatal hernia, 8/06 and 3/07. Now has abdominal pain and inability to swallow. UGI series shows recurrent paraesophageal hiatal hernia.

20. Anterior Nissen Gastropexy For Paraesophageal HH The axis of one line of sutures keeps the gastroesophageal junction in the abdomen. The axis of the second line prevents the greater curvature from rotating on the first line or the GE junction, thereby offsetting any tendency of the fundus to return to the chest. The sutures attach the anterior surface of the stomach to the diaphragm and posterior rectus sheath. This is it, if you really need to use a gastropexy for this condition.

21. Gastropexy Most pexy operations for abdominal viscera fail in the long run. Don’t trust intuition. Results contradict. Most pexy operations for abdominal viscera fail in the long run. Don’t trust intuition. Results contradict. Gastropexy, cecopexy, sigmoidopexy, and nephropexy return to their original unwanted orientations. Adding a gastrostomy doesn’t secure a gastropexy: the stomach still pulls away. Gastropexy, cecopexy, sigmoidopexy, and nephropexy return to their original unwanted orientations. Adding a gastrostomy doesn’t secure a gastropexy: the stomach still pulls away. Posterior gastropexy is the only pexy that predictably works.

22. Gastropexy Thus, anterior gastropexy was largely abandoned as a primary operation for paraesophageal hernias by 1990. Thus, anterior gastropexy was largely abandoned as a primary operation for paraesophageal hernias by 1990. The principal remaining use is as an emergency measure in bad risk patients. The principal remaining use is as an emergency measure in bad risk patients. Follow Nissen’s method, however. One or two stitches plus a gastrostomy is not enough. Follow Nissen’s method, however. One or two stitches plus a gastrostomy is not enough.

23. Conclusions There is no difference between Type II & Type III hernias. There is a continuous spectrum. There is no difference between Type II & Type III hernias. There is a continuous spectrum. Surgery is indicated only for symptoms. Surgery is indicated only for symptoms. The sac must be completely separated from the stomach and trimmed, but not “entirely excised.” The sac must be completely separated from the stomach and trimmed, but not “entirely excised.” Fundoplication routine. Fundoplication routine. A 360° wrap cures the reflux in most patients. A 360° wrap cures the reflux in most patients. Mesh may or may not be used, but is not important in most cases. Mesh may or may not be used, but is not important in most cases. Anterior gastropexy must be done right. Anterior gastropexy must be done right.