Thadeus Trus
Presentation
A 66-year-old man presents to the clinic for evaluation of a large hiatal hernia discovered on chest x-ray. He has a significant history of gastroesophageal reflux disease (GERD) characterized by substernal burning and regurgitation, which is controlled by a proton pump inhibitor taken daily. More recently, he is experiencing mild postprandial chest discomfort and early satiety and has lost 20 lb. He also notes occasional dysphagia and vomiting. On exam, he is well appearing. Heart sounds are normal and his lungs are clear. Occasional bowel sounds are heard on auscultation of the chest. On examination, his abdomen is soft without tenderness or palpable masses, and he has no palpable lymphadenopathy. Upon laboratory investigations, he is noted to have a hemoglobin level of 10.5. Recent colonoscopy was negative.
Differential Diagnosis
The patient’s nonspecific symptoms can be associated with a variety of conditions such as GERD, biliary disease such as cholelithiasis and colic, cardiac disease, esophageal pathology including esophagitis and hiatal hernia, and malignancy. His heartburn and spontaneous regurgitation may reflect a hiatal hernia. Additionally, his symptom progression and current dysphagia and vomiting can be indicative of a paraesophageal hernia or intrathoracic stomach.
Workup
All patients, particularly older patients, with atypical chest pain should be evaluated for underlying coronary artery disease as the cause of their symptoms. Once this is excluded, along with other potential pathology, suspected paraesophageal hernias should be evaluated with a barium swallow. This study provides a “snap shot” of the esophagogastric anatomy and allows for classification of the type of hiatal hernia. Any organoaxial rotation of the stomach can be seen as well. It is less sensitive for the evaluation of mucosal pathology and esophageal motility. Endoscopy (EGD) should be performed on all patients to assess for esophagitis, Barrett’s esophagus, peptic stricture, Cameron’s ulcers, and malignancy. Of note, Cameron’s ulcers are the most common source of anemia in these patients but are not always found on endoscopy; they are transient in nature and can be difficult to visualize in the distorted gastric anatomy associated with large paraesophageal hernias. Peptic strictures, if found, should be biopsied and dilated as needed preoperatively. Although esophageal manometry can be done, it is often difficult to pass the probe effectively in the setting of a paraesophageal hernia or an intrathoracic stomach. Manometry is not critical to the preoperative workup.
The patient in this scenario undergoes further workup of his hiatal hernia. A barium swallow demonstrates a large paraesophageal hernia: The gastroesophageal junction (GEJ) remains at the level of the diaphragm with gastric antrum herniating into the chest (Figure 1). An EGD is then performed, which confirms a large hiatal hernia with a paraesophageal component. A Cameron’s ulcer is found near the hiatal hernia (Figure 2A,B). The surveyed mucosa is otherwise normal.
FIGURE 1 • Barium contrast study showing a large para esophageal hernia.
FIGURE 2 • Upper endoscopy demonstrating a large paraesophageal hernia with Cameron’s ulcer (arrow) and otherwise normal mucosa.
Discussion
The patient in this scenario has a Type II hiatal hernia. There are four types of hiatal hernias. Type I or the sliding hiatal hernia is the most common, accounting for 90% to 95% of hiatal hernias. It is characterized by migration of the GEJ through the hiatus. Type II hernias are true paraesophageal hernias where the GEJ remains in its normal anatomic position below the diaphragm; the gastric fundus herniates above the GEJ though the hiatus. Type III or mixed-type hiatal hernias are characterized by herniation of both the GEJ and gastric fundus above the diaphragm. These tend to be large hernias with more than 50% of the stomach located in the mediastinum. Finally, Type IV hiatal hernias occur when a Type II or III hernia exists and other organs (e.g., spleen and/or colon) migrate into the thorax as well.
Paraesophageal hernias are more common in elderly patients aged 60 to 70 years. It remains unclear as to why certain individuals develop paraesophageal hernias. It is theorized that hernia formation is likely related to the progression of a hiatal hernia in conjunction with increased intra-abdominal pressure, as is seen in obesity and COPD.
Diagnosis and Treatment
Symptomatic patients with paraesophageal hernias warrant surgical repair. Rarely, patients present with acute obstruction secondary to gastric volvulus. These patients should be decompressed with a nasogastric tube. If necessary, endoscopy can be utilized for decompression. This will often provide relief of the patient’s symptoms and allows for preoperative resuscitation. These patients should be definitively repaired within a few days of presentation. Controversy exists regarding the surgical management of asymptomatic paraesophageal hernias. Historically, studies suggest that up to 30% of asymptomatic patients with paraesophageal hernias will develop potentially devastating complications such as strangulation and perforation. However, recent data suggests that the incidence of developing such complications is much lower than the previously reported. Because of this there is some support for the observation of asymptomatic patients aged 65 years or older. For the most part however, most patients with paraesophageal hernias are at a minimum, mildly symptomatic with occasional bloating, heartburn, or episodic dysphagia. Given the likelihood of symptom progression over time in this elderly population, we advocate early elective repair.
Surgical Approach
Various approaches to paraesophageal hernia repair have been described, including open transabdominal, transthoracic (thoracotomy), or laparoscopic transabdominal. Recently, the laparoscopic approach has become the preferred method of repair. Yet controversy exists in the literature regarding the long term efficacy of laparoscopic paraesophageal hernia repair versus open repair. Advocates of an open approach argue that there is a lower recurrence rate with a repair performed via laparotomy or thoracotomy. Laparoscopic advocates contend that not all recurrences warrant surgical intervention as many are asymptomatic. Furthermore, the use of biomesh as part of the paraesophageal hernia repair has been shown to decrease recurrence rates at least in the short term. Because of the less invasive approach, we advocate laparoscopic repair of paraesophageal hernias. In this elderly patient population, the proven benefits related to perioperative recovery far outweigh the potential for a recurrence of unclear clinical significance.
Regardless of the surgical approach, there are four fundamental steps to paraesophageal hernia repair:
1. Complete reduction of the stomach and GEJ into the abdominal cavity without tension
2. Complete reduction and excision of the hernia sac
3. Crural closure
4. Fixation of the stomach in the abdomen with fundoplication or gastropexy
Laparoscopic paraesophageal hernia repair is performed with the patient positioned split-legged or in lithotomy with the surgeon standing between the patient’s legs. Access to the abdominal cavity can be gained with an open or closed technique. The camera port should be placed approximately 15 to 17 mm inferior to the xiphoid process and to the left of midline, through the rectus muscle. Five-millimeter ports are placed under direct vision along the left and right costal margin, each approximately 10 cm away from the xiphoid process. These serve as the surgeon’s operating ports. A lateral 5-mm port is placed further along the right costal margin for the atraumatic liver grasper; this is used to elevate the left liver lobe facilitating exposure of the hiatus. Another 5-mm port is placed in the right upper quadrant for the assistant. The hernia is first reduced with gentle traction. Excessive traction can lead to injury to the stomach and should be avoided. Dissection of the hernia sac begins along the inner border of the crura—we prefer starting this dissection along the left crus, continuing over the crural arch to the right crus. This plane between the hernia sac and the crura is developed bluntly and dissection proceeds into the mediastinum. Care must be taken to identify the pleural edges and reflect them laterally. Once reduced intra-abdominally, any excess sac should be removed from its gastric attachments. The short gastric vessels are then divided which further facilitates exposure of the base of the crura. There is often a large posterior esophageal fat pad which must be reduced to allow for complete visualization of the crural base. This allows for placement of a Penrose drain around the esophagus and vagus nerves for traction. Esophageal lengthening is achieved with circumferential dissection of the esophagus within the mediastinum. The crural defect is then closed posterior to the esophagus using multiple, nonabsorbable pledgeted sutures. A partial or full fundoplication over a 60-French bougie is then fashioned. Any large defect is should be reinforced with a U-shaped biomesh sutured to the apices of the crura. Caution must be exercised in large, long-standing paraesophageal hernias, as the vena cava can be pulled quite close to the right crus.
Potential pitfalls of the operation include pneumothorax, injury to the vagus, serosal injury to the stomach, and esophageal injury. If a pneumothorax is recognized, one can usually continue the operation with the patient on positive-pressure ventilation without difficulty. These more often occur on the left, where it can be difficult to identify pleural edge from hernia sac. At the conclusion of the case, the pneumothorax can be evacuated with a red-rubber catheter placed through the hiatal closure and put to water-seal. Injury to the anterior vagus nerve can occur during reduction of the hernia sac. One must be sure to identify the nerve that is often lifted off of the esophagus, making it more susceptible to injury. Excessive traction on the stomach during reduction can result in serosal tears. These should be primarily repaired at the time of injury. Finally, although esophageal perforations are rare, inadvertent myotomies during dissection of the hernia sac are not infrequent.
Special Intraoperative Considerations
Gastric perforation may occur in the patient with acute gastric volvulus. This can usually be avoided with early decompression and surgical intervention. These perforations usually occur on the anterior surface of the fundus and can be repaired primarily laparoscopically.
Short esophagus can be a challenge, limiting esophageal mobilization to allow for 3 to 4 cm of tension-free, intra-abdominal esophagus. Esophageal length can usually be achieved by high mediastinal dissection. Rarely, a Collis gastroplasty is warranted.
Management of the critically ill patient can be difficult. If the patient cannot tolerate extensive surgery, the surgeon should attempt separation of the sac from the esophagus and stomach, crural closure, and gastropexy (G-tube or suture pexy).
Postoperative Management
Postoperative CXR is not routinely performed unless clinically indicated. Small pneumothoraces are often seen and not treated. Routine nasogastric decompression is not warranted. Patients are left NPO the day of surgery and antiemetics are given prophylactically to prevent retching. Patients are started on a clear liquid diet without carbonated beverages on postoperative day 1 and advanced to a mechanical soft diet as tolerated. Patients are usually discharged home on postoperative day 1 or day 2, depending on oral intake and mobility.
Unexplained tachycardia or shortness of breath mandates immediate UGI study with gastrograffin followed by barium to evaluate for a leak. If a leak is found, immediate exploration with primary repair and drainage is warranted. Exploratory laparoscopy can also be liberally used to rule out postoperative bleeding or leak.
Case Conclusion
The patient undergoes a laparoscopic paraesoph ageal hernia repair with Toupet fundoplication. He does well ostoperatively and is discharged to home on postoperative day 2.
TAKE HOME POINTS
· Paraesophageal hernias ae common in the elderly.
· Symptoms may be vague and nonspecific.
· Most paraesophageal hernias should be repaired electively.
· Paraesophageal hernias can be safely repaired through a laparoscopic approach.
· Principles of repair include complete reduction of the hernia sac, crural closure, and fundoplication/gastropexy.
SUGGESTED READINGS
Edye MB, Canin-Endres J, Gattorno F, et al. Durability of laparoscopic repair of paraesophageal hernia. Ann Surg. 1998;228(4):528–535.
Lal DR, Pellegrini CA, Oeslschlager BK. Laparoscopic repair of paraesophageal hernia. Surg Clin N Am. 2005;85:105–118.
Oelschlager BK, Pellegrini CA. Paraesophageal hernias: open, laparoscopic, or thoracic repair? Chest Surg Clin N Am. 2001;11(3):589–603.
Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatus hernia. Long term results with 1030 patients. J Thorac Cardiovasc Surg. 1967;53(1):33–54.