Departments of Surgery1 "A" and Radiology2, Meir Medical Center,
Kfar-Sava and the Tel-Aviv University School of Medicine
Background: Large Paraesophageal diaphragmatic hernias (PEH) are challenging conditions, with considerable danger of life threatening complications, including incarceration/strangulation, bleeding and volvulus, and it is an absolute indication for surgery. The laparoscopic repair of giant PEH can be technically difficult, especially when chronic partial gastric volvulus is found. Pre-operative knowledge of the anatomical position of the stomach can be an important tool influencing the operative strategy.
Material and Methods: We retrospectively reviewed our experience with patients operated upon for giant PEH with emphasis on the pre-operative investigation, technical aspects of the operation, peri-operative complication and late results. All patients were followed –up at the out-patient clinic, and interviewed with regard to dysphagia, heartburn, and satisfaction. In most patients a late barium study was performed.
Results: During a 20-month period, between December 2002 and August 2004, ten patients were operated upon with a pre-operative diagnosis of giant paraesophageal hernias. Ct-scans with 3-D reconstructions, were the best modality to demonstrate the anatomy of the PEH. Gastroscopy and barium studies were performed in all patients, but their findings correlated poorly with the operative findings. Partial gastric volvulus was found at operation in 6 patients. All patients were operated upon laparoscopically. The mean operative time was 153 minutes (range 104 to 252 minutes). There were no conversions to open surgery, but in two cases the routine gastrografin swallow, in the following day, revealed recurrent gastric herniation in two patients. They were operated upon immediately (one laparoscopically and the other via laparotomy), and the condition was successfully repaired. In both cases the reason for failure was an incomplete dissection of the hernia sac from the stomach. There were no other complications. The diaphragm was primarily repaired with sutures in 3 patients and with PFTE mesh in the remaining 7, at the surgeons' discretion. Nissen fundoplication was performed in 6 patients and Toupet fundoplication in the remaining 6 patients. There was no correlation between the type of repair and success. On follow-up, three patients had mild dysphagia, but became asymptomatic 3 months after the operation.
Conclusions:Laparoscopic repair of giant paraesophageal hernias are safe and effective. Pre-operative investigation should include a Ct-scan. Complete and meticulous dissection of the hernia sac is imperative for success. Chronic partial gastric volvulus is not a contraindication for laparoscopic repair.