Laparoscopic management of large paraesophageal hiatal hernia.

BACKGROUND

Large paraesophageal hernias (POHs) predominantly occur in the elderly population. Early repair is recommended to avoid the risks associated with gastric volvulus.

METHODS

Data were collected prospectively during an 8-year period. Laparoscopic repair of POHs initially included circumcision of the sac and mesh hiatal repair. Sac excision and suture hiatal repair were later adopted. A fundoplication was also included, initially as a selective procedure.

RESULTS

Fifty-three patients with large POHs were treated by one surgeon. All had attempted laparoscopic repair, with four conversions to an open procedure. Symptomatic hernia recurrence occurred in five patients (9%). The 21 patients who had sac excision, hiatal repair, and fundoplication have remained free of symptomatic recurrence. The postoperative morbidity rate was 13%, with one death.

CONCLUSIONS

Laparoscopic repair of large POHs remains feasible. We advocate complete sac excision, hiatal repair, fundoplication, and gastropexy to prevent early recurrence.