Removal of the sac during surgery for the repair of "giant" paraesophageal hernias.

BACKGROUND

The presence of a large paraesophageal hernia is a source of concern in foregut surgery. Thus, scholars have focused on ascertaining the optimal surgical approach, methods for reinforcing the esophageal hiatus, and strategies for preventing hernia recurrence and gastroesophageal reflux.

AIM: To investigate the outcomes of surgery for giant paraesophageal hernias without sac removal.

METHODS

Sixty-six consecutive patients who underwent surgery for a giant paraesophageal hernia between May 2010 and December 2024 were included in this retrospective study. The pre- and postoperative examinations included upper gastrointestinal endoscopy, X-ray with barium contrast swallow, contrast-enhanced computed tomography (CT) scans of the chest and abdomen, 24-hour potential hydrogen esophageal monitoring, and esophagomanometry. The study group included 36 patients who underwent surgery without sac removal, and the control group included 30 patients who underwent surgery with sac removal.

RESULTS

Fifty-two patients (28 in the study group and 24 in the control group) underwent laparoscopic procedures, 10 (6 in the study group and 4 in the control group) underwent open procedures, and 4 (2 in each group) underwent conversion procedures. The operative time and postoperative length of stay were significantly longer in the control group than in the study group. In 12 patients in the study group, X-ray examination on postoperative days 3-5 revealed air-fluid levels at the site of the remaining hernia sac; all air-fluid levels disappeared without intervention 2 months later. Postoperative day 60 CT and X-ray examinations revealed no pathological changes related to the hernia sac in the mediastinum.

CONCLUSION

Removal of the hernia sac during surgery for giant paraesophageal hernias is not mandatory. Further large-scale multicentric randomized trials are needed for a more detailed investigation in this field.