Surgical management of paraesophageal hernia
- Michael Rosen, MD
Michael Rosen, MD
- Section Editor — Hernia Surgery
- Professor of Surgery
- Cleveland Clinic Foundation
- Jeffrey Blatnik, MD
Jeffrey Blatnik, MD
- Assistant Professor of Surgery
- Washington University School of Medicine
- Section Editors
- Joseph S Friedberg, MD
Joseph S Friedberg, MD
- Section Editor — Thoracic Surgery
- Charles Reid Edwards Professor of Surgery
- University of Maryland
- Jeffrey Marks, MD
Jeffrey Marks, MD
- Section Editor — Minimally Invasive Surgery
- Professor of Surgery
- University Hospitals
- Case Medical Center
A paraesophageal hernia is an uncommon type of hiatal hernia that mainly affects older adults with a median age of presentation between 65 and 75 years [1-3]. The hernia includes a peritoneal layer that forms a true hernia sac, distinguishing it from the more common sliding hiatal hernia. Surgical management is indicated when medical management fails to control symptoms (eg, gastroesophageal reflux, dysphagia, regurgitation, anemia, dyspnea, epigastric, or abdominal pain) or when there is a complication (eg, bleeding, obstruction, or gastric volvulus) [4-8].
Surgical management of a paraesophageal hernia will be reviewed here. The anatomy, physiology, types, symptoms, and diagnosis of a hiatal hernia are discussed elsewhere. (See "Hiatus hernia".)
There are four types of hiatal hernias, three of which are paraesophageal hernias (figure 1). The four types of hiatal hernias can be distinguished by the hernia contents and the position of the gastroesophageal junction:
●Type I or sliding hiatus hernia is characterized by the displacement of the gastroesophageal junction above the diaphragm. The stomach remains in its usual longitudinal alignment, and the fundus remains below the gastroesophageal junction.
●Type II or "true" paraesophageal hernia results from a localized defect in the phrenoesophageal membrane where the gastric fundus serves as a lead point of herniation, while the gastroesophageal junction remains fixed to the preaortic fascia and the median arcuate ligament [7,8].
- Luketich JD, Nason KS, Christie NA, et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. J Thorac Cardiovasc Surg 2010; 139:395.
- Geha AS, Massad MG, Snow NJ, Baue AE. A 32-year experience in 100 patients with giant paraesophageal hernia: the case for abdominal approach and selective antireflux repair. Surgery 2000; 128:623.
- Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal hernia repair. Arch Surg 1997; 132:586.
- Hill LD. Incarcerated paraesophageal hernia. A surgical emergency. Am J Surg 1973; 126:286.
- Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long-term results with 1,030 patients. J Thorac Cardiovasc Surg 1967; 53:33.
- Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: operation or observation? Ann Surg 2002; 236:492.
- Kaiser LR, Singal S. Diaphragm. In: Surgical Foundations: Essentials of Thoracic Surgery, Elsevier Mosby, Philadelphia, PA 2004. p.294.
- Miller JI Jr. Chapter 89. Bacterial infections of the lungs and bronchial compressive disorders. In: General Thoracic Surgery, 7th ed, Shields TW, LoCicero J, Reed CE, Feins RH. (Eds), Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia 2009. Vol 1, p.294.
- Davis SS Jr. Current controversies in paraesophageal hernia repair. Surg Clin North Am 2008; 88:959.
- Kohn GP, Price RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia. Surg Endosc 2013; 27:4409.
- Lidor AO, Steele KE, Stem M, et al. Long-term quality of life and risk factors for recurrence after laparoscopic repair of paraesophageal hernia. JAMA Surg 2015; 150:424.
- Low DE, Unger T. Open repair of paraesophageal hernia: reassessment of subjective and objective outcomes. Ann Thorac Surg 2005; 80:287.
- Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 2000; 190:553.
- Ferri LE, Feldman LS, Stanbridge D, et al. Should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach? Surg Endosc 2005; 19:4.
- Frantzides CT, Carlson MA, Loizides S, et al. Hiatal hernia repair with mesh: a survey of SAGES members. Surg Endosc 2010; 24:1017.
- Paul S, Nasar A, Port JL, et al. Comparative analysis of diaphragmatic hernia repair outcomes using the nationwide inpatient sample database. Arch Surg 2012; 147:607.
- Pierre, AF, Luketich, JD. Laparoscopic repair of giant paraesophageal hernias. The cardiothoracic surgery network. www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-9.html (Accessed on February 09, 2011).
- Mattioli S, Lugaresi M, Ruffato A, et al. Collis-Nissen gastroplasty for short oesophagus. Multimed Man Cardiothorac Surg 2015; 2015.
- COLLIS JL. An operation for hiatus hernia with short oesophagus. Thorax 1957; 12:181.
- Awad ZT, Filipi CJ, Mittal SK, et al. Left side thoracoscopically assisted gastroplasty: a new technique for managing the shortened esophagus. Surg Endosc 2000; 14:508.
- Terry ML, Vernon A, Hunter JG. Stapled-wedge Collis gastroplasty for the shortened esophagus. Am J Surg 2004; 188:195.
- Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg 2002; 137:649.
- Müller-Stich BP, Holzinger F, Kapp T, Klaiber C. Laparoscopic hiatal hernia repair: long-term outcome with the focus on the influence of mesh reinforcement. Surg Endosc 2006; 20:380.
- Oelschlager BK, Pellegrini CA, Hunter J, et al. Biologic prosthesis reduces recurrence after laparoscopic paraesophageal hernia repair: a multicenter, prospective, randomized trial. Ann Surg 2006; 244:481.
- Lee YK, James E, Bochkarev V, et al. Long-term outcome of cruroplasty reinforcement with human acellular dermal matrix in large paraesophageal hiatal hernia. J Gastrointest Surg 2008; 12:811.
- Oelschlager BK, Pellegrini CA, Hunter JG, et al. Biologic prosthesis to prevent recurrence after laparoscopic paraesophageal hernia repair: long-term follow-up from a multicenter, prospective, randomized trial. J Am Coll Surg 2011; 213:461.
- Memon MA, Memon B, Yunus RM, Khan S. Suture Cruroplasty Versus Prosthetic Hiatal Herniorrhaphy for Large Hiatal Hernia: A Meta-analysis and Systematic Review of Randomized Controlled Trials. Ann Surg 2016; 263:258.
- Stadlhuber RJ, Sherif AE, Mittal SK, et al. Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc 2009; 23:1219.
- Casabella F, Sinanan M, Horgan S, Pellegrini CA. Systematic use of gastric fundoplication in laparoscopic repair of paraesophageal hernias. Am J Surg 1996; 171:485.
- Krähenbühl L, Schäfer M, Farhadi J, et al. Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach. J Am Coll Surg 1998; 187:231.
- Müller-Stich BP, Achtstätter V, Diener MK, et al. Repair of Paraesophageal Hiatal Hernias—Is a Fundoplication Needed? A Randomized Controlled Pilot Trial. J Am Coll Surg 2015; 221:602.
- Ponsky J, Rosen M, Fanning A, Malm J. Anterior gastropexy may reduce the recurrence rate after laparoscopic paraesophageal hernia repair. Surg Endosc 2003; 17:1036.
- Kercher KW, Matthews BD, Ponsky JL, et al. Minimally invasive management of paraesophageal herniation in the high-risk surgical patient. Am J Surg 2001; 182:510.
- Yates RB, Hinojosa MW, Wright AS, et al. Laparoscopic gastropexy relieves symptoms of obstructed gastric volvulus in highoperative risk patients. Am J Surg 2015; 209:875.
- Puri V, Kakarlapudi GV, Awad ZT, Filipi CJ. Hiatal hernia recurrence: 2004. Hernia 2004; 8:311.
- de la Fuente SG, Khuri SF, Schifftner T, et al. Comparative analysis of vagotomy and drainage versus vagotomy and resection procedures for bleeding peptic ulcer disease: results of 907 patients from the Department of Veterans Affairs National Surgical Quality Improvement Program database. J Am Coll Surg 2006; 202:78.
- Itano H, Okamoto S, Kodama K, Horita N. Transthoracic Collis-Nissen repair for massive type IV paraesophageal hernia. Gen Thorac Cardiovasc Surg 2008; 56:446.
- Patel HJ, Tan BB, Yee J, et al. A 25-year experience with open primary transthoracic repair of paraesophageal hiatal hernia. J Thorac Cardiovasc Surg 2004; 127:843.
- Maziak DE, Todd TR, Pearson FG. Massive hiatus hernia: evaluation and surgical management. J Thorac Cardiovasc Surg 1998; 115:53.
- Larusson HJ, Zingg U, Hahnloser D, et al. Predictive factors for morbidity and mortality in patients undergoing laparoscopic paraesophageal hernia repair: age, ASA score and operation type influence morbidity. World J Surg 2009; 33:980.
- Poulose BK, Gosen C, Marks JM, et al. Inpatient mortality analysis of paraesophageal hernia repair in octogenarians. J Gastrointest Surg 2008; 12:1888.
- Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of laparoscopic repair of paraesophageal hernia. Surg Endosc 2002; 16:745.
- White BC, Jeansonne LO, Morgenthal CB, et al. Do recurrences after paraesophageal hernia repair matter? : Ten-year follow-up after laparoscopic repair. Surg Endosc 2008; 22:1107.
- Rathore MA, Andrabi SI, Bhatti MI, et al. Metaanalysis of recurrence after laparoscopic repair of paraesophageal hernia. JSLS 2007; 11:456.
- Carlson MA, Condon RE, Ludwig KA, Schulte WJ. Management of intrathoracic stomach with polypropylene mesh prosthesis reinforced transabdominal hiatus hernia repair. J Am Coll Surg 1998; 187:227.
- INDICATIONS FOR SURGICAL REPAIR
- PREOPERATIVE EVALUATION
- OPERATIVE APPROACHES
- TRANSABDOMINAL REPAIR
- Dissection of the hiatus and hernia sac
- Esophageal mobilization
- Closure of hiatal defect
- Anterior gastropexy
- Postoperative management
- TRANSTHORACIC REPAIR
- PATIENT OUTCOMES
- Mortality and morbidity
- - Reoperation
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS