Laparoscopic Approach to Repair Hiatal Hernias: Our Experience in a Tertiary Care Hospital

INTRODUCTION

Hiatus hernia is the bulging of an abdominal structure other than the esophagus into the chest cavity through the hiatus of the diaphragm. Hiatal hernia is often associated with symptomatic GERD.¹ The relationship between hiatal hernia and gastroesophageal reflux and proposed surgical options for correcting the defect, as noted by Allison, namely, returning the stomach to the abdomen and repairing the diaphragmatic hiatus.² The GEJ to become intrathoracic consists of a combination of hiatus enlargement, lengthening of the phrenoesophageal ligament, and increased intra-abdominal pressure. There are four types of hiatal hernia. Type I, sliding hiatal hernias, make up almost 95% of all hiatal hernias. The other three types of hiatal hernias are broadly classified as paraesophageal. Compared to a type I hernia, which does not have a hernial sac, all PEHs are covered all around by a peritoneum layer, which forms a real hernial sac. Type II PEH is the rarest.^3,4

It is difficult to determine the actual incidence of a hiatal hernia because an asymptomatic hiatal hernia often goes undetected. However, the symptomatic hernia associated with GERD should be examined pathophysiologically, as the incidence of GERD is increasing worldwide.⁵ Compared to the West, the East has the lower incidence, but recently the incidence is increasing in our part of the world.⁶

Proton pump inhibitors are a preferred treatment option for symptom relief. Surgical treatment is usually followed by medical treatment. Depending on the severity of symptoms and the type of hernia affected, surgical treatment will be decided.^7,8 Surgical reconstruction of the paraesophageal hernia has two main goals: to restore normal anatomy by returning the GEJ and stomach to the abdomen and to correct the condition that contributed to the development of the anatomical problem, GERD. There are several approaches to the surgical treatment of paraesophageal hernias; a transthoracic, transabdominal, or laparoscopic approach.^9–11

Laparoscopic repair is a good approach these days. It offers various advantages to both the patient and the surgeon. It is generally performed by a general abdominal surgeon as it usually involves abdominal access. Laparoscopic repair significantly reduces postoperative complications and is the procedure of choice in most centers.

MATERIALS AND METHODS

The present study protocol was reviewed and approved by the Institutional Review Board of Hospital, which waived the requirement for informed patient consent due to the retrospective nature of the work. A single team of surgeons performed all of the interventions. Eighteen patients with primary hiatal hernia who underwent laparoscopic surgery from 2009 to 2017 were examined. Routine preoperative tests were performed (e.g., physical exam, standard laboratory tests, and pulmonary function tests). In addition, an esophagogastroduodenoscopy, computed tomography of the thorax and abdomen, and barium esophagography were performed preoperatively. However, esophageal manometry and 24-hour ambulatory pH monitoring were not performed routinely. The indications for surgery were the presence of symptoms (reflux or obstructive symptoms) and the patient’s desire for surgical repair and consent. The latter was generally true of asymptomatic cases discovered by chance. Consent to the operation was obtained from the patients after they had been adequately educated about the natural course of an untreated hiatal hernia and informed about the operation, including details of the procedure and the associated risks. Based on the postoperative clinical stability of each patient, feeding was started after it was confirmed that no abnormalities occurred. Patients who showed no symptoms on the oral soft diet were discharged. All patients visited the outpatient department 2 weeks postoperatively for a general check of their condition and symptoms. Follow-up examinations were carried out every 3 months for the first year and every 6 months thereafter. In this study, clinical features, surgical factors, and postoperative outcomes were analyzed for all patients.

RESULTS

The follow-up period ranged from 12 months to 24 months. The mean follow-up time was about 12 months.

• In total, 39 patients underwent laparoscopic hernia surgery with fundoplication, including 26 women and 13 men (Table 1).

• Most patients present with symptoms of heartburn or epigastric pain. Some of the patients presented with dyspepsia. Few patients were diagnosed by chance.

• The mean age was 42 years (25–75) (Table 2).

• The operating time was 150–250 minutes with an average time of 194 minutes. No patient required a switch from the laparoscopic procedure to the open technique (Table 3).

• The hospital stay was 4–7 days with an average stay of 4.5 days. This included a one-day preoperative admission.

• There were no deaths during or after the procedure.

• Pain: A total of 15 patients complained of pain on the 1st postoperative day that required analgesia around the clock. This number decreased to 5 by day 3. At the time of discharge (maximum interval of 7 days and median 5.5 days), none of the patients was in pain.

• Two patients had symptoms of dysphagia at the outpatient follow-up visit. These patients showed no significant imaging findings and no difficulty in eating, and the symptoms were well controlled with medication.

DISCUSSION

The presentation of the hiatal hernia can be very different, it can be asymptomatic, or it can appear with different symptoms such as reflux or obstructive symptoms. Diagnosing hiatal hernia is difficult, but with the advent of new diagnostic tools, the rate of diagnosis has recently increased.^12,13 Because of the morbidity and effectiveness associated with open surgery, medical treatment is the preferred approach to control symptoms of GERD.¹⁴ But since the introduction of laparoscopic surgery, the morbidity associated with the procedure has decreased dramatically. Various studies have concluded that the laparoscopic approach is just as effective as open surgery, but with reduced postoperative complications, recovery time, and almost the same recurrence rates.¹⁵ In addition, several studies have shown that laparoscopic surgery is the medical treatment in terms of long-term symptomatic improvement and cost-effectiveness.^16–18 Regarding asymptomatic patients, some suggest waiting and observing. However, experts believe that asymptomatic hiatal hernias are rare and studies have shown a progression from asymptomatic to symptomatic about 14% per year.¹⁹ The minimally invasive approach to repairing paraesophageal hernias is now the preferred approach because of the lower incidence of morbidities, less pain, and longer hospital stay compared to the open approach.^15,20 The recurrence rate of the laparoscopic approach is similar to that of the open approach and has decreased over time with increasing experience and better learning of the technique.²¹

The SAGES set out the technical considerations for surgery in their 2013 guidelines for the management of hiatal hernias.²² The infra diaphragmatic position of the gastroesophageal junction is one of the most important aspects of hernia repair. Collis gastroplasty is the answer to the short esophagus as suggested by O’Rourke et al. in their study.²³ None of the patients in our study required Collis gastroplasty. The complexity of hiatal hernia surgery requires a significant learning curve. Okrainec et al. reported that surgeons need at least 20 cases of experience to achieve a reasonably low recurrence rate.²⁴ We have been able to successfully carry out this operation to date without complications and without recurrences. The limitations of our retrospective study were the small sample size and the relatively short follow-up.²⁵

CONCLUSION

We conclude that laparoscopic repair of hiatal hernias is a viable technique with satisfactory surgical results. Although it is a complex operation with a significant learning curve, thoracic surgeons with sufficient experience in laparoscopy would be able to perform the operation.

REFERENCES

1. Müller-Stich BP, Holzinger F, Kapp T, et al. Laparoscopic hiatal hernia repair: Long-term outcome with the focus on the influence of mesh reinforcement. Surg Endosc 2006;20(3):380–384. DOI: 10.1007/s00464-004-2272-6.

2. Allison PR. Reflux esophagitis, sliding hiatal hernia, and the anatomy of repair. Surg Gynecol Obstet 1951;92(4):419–431. PMID: 14835197

3. Hill LD, Tobias JA. Paraesophageal hernia. Arch Surg 1968;96(5):735–744. DOI: 10.1001/archsurg.1968.01330230043007.

4. Ozdemir IA, Burke WA, Ikins PM. Paraesophageal hernia. A life-threatening disease. Ann Thorac Surg 1973;16(6):547–554. DOI: 10.1016/s0003-4975(10)65035-7.

5. Hill LD, Kozarek RA, Kraemer SJ, et al. The gastroesophageal flap valve: In vitro and in vivo observations. Gastrointest Endosc 1996;44(5):541–547. DOI: 10.1016/s0016-5107(96)70006-8.

6. Petersen H, Johannessen T, Sandvik AK, et al. Relationship bet-ween endoscopic hiatus hernia and gastroesophageal reflux symptoms. Scand J Gastroenterol 1991;26(9):921–926. DOI: 10.3109/00365529108996243.

7. Schlottmann F, Herbella FA, Allaix ME, et al. Surgical treatment of gastroesophageal reflux disease. World J Surg 2017;41(7):1685–1690. DOI: 10.1007/s00268-017-3955-1.

8. Siegal SR, Dolan JP, Hunter JG. Modern diagnosis and treatment of hiatal hernias. Langenbecks Arch Surg 2017;402(8):1145–1151. DOI: 10.1007/s00423-017-1606-5.

9. 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(3):843–849. DOI: 10.1016/j.jtcvs.2003.10.054.

10. Low DE, Unger T. Open repair of paraesophageal hernia: Reassessment of subjective and objective outcomes. Ann Thorac Surg 2005;80(1):287–294. DOI: 10.1016/j.athoracsur.2005.02.019.

11. Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases. Ann Surg 2000;232(4):608–618. DOI: 10.1097/00000658-200010000-00016.

12. Kim KM, Cho YK, Bae SJ, et al. Prevalence of gastroesophageal reflux disease in Korea and associated health-care utilization: A national population-based study. J Gastroenterol Hepatol 2012;27(4):741–745. DOI: 10.1111/j.1440-1746.2011.06921.x.

13. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013;108(3):308–328. DOI: 10.1038/ajg.2012.444.

14. Iwakiri K, Kinoshita Y, Habu Y, et al. Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2015. J Gastroenterol 2016;51:751–767. DOI: 10.1007/s00535-016-1227-8.

15. Zehetner J, Demeester SR, Ayazi S, et al. Laparoscopic versus open repair of paraesophageal hernia: The second decade. J Am Coll Surg 2011;212(5):813–820. DOI: 10.1016/j.jamcollsurg.2011.01.060.

16. Mehta S, Bennett J, Mahon D, et al. Prospective trial of laparoscopic Nissen fundoplication versus proton pump inhibitor therapy for gastroesophageal reflux disease: Seven-year follow-up. J Gastrointest Surg 2006;10(9):1312–1316. DOI: 10.1016/j.gassur.2006.07.010.

17. Anvari M, Allen C, Marshall J, et al. A randomized controlled trial of laparoscopic Nissen fundoplication versus proton pump inhibitors for the treatment of patients with chronic gastroesophageal reflux disease (GERD): 3-year outcomes. Surg Endosc 2011;25(8):2547–2554. DOI: 10.1007/s00464-011-1585-5.

18. Grant AM, Boachie C, Cotton SC, et al. Clinical and economic evaluation of laparoscopic surgery compared with medical management for gastro-oesophageal reflux disease: 5-year follow-up of multicentre randomised trial (the REFLUX trial). Health Technol Assess 2013;17(22):1–167. DOI: 10.3310/hta17220.

19. Stylopoulos N, Gazelle GS, Rattner DW. Paraesophageal hernias: Operation or observation? Ann Surg 2002;236(4):492–500. DOI: 10.1097/00000658-200210000-00012.

20. Schauer PR, Ikramuddin S, McLaughlin RH, et al. Comparison of laparoscopic versus open repair of paraesophageal hernia. Am J Surg 1998;176(6):659–665. DOI: 10.1016/S0002-9610(98)00272-4.

21. Karmali S, McFadden S, Mitchell P, et al. Primary laparoscopic and open repair of paraesophageal hernias: A comparison of short-term outcomes. Dis Esophagus 2008;21:63–68. DOI: 10.1111/j.1442-2050.2007.00740.

22. Kohn GP, Price RR, DeMeester SR, et al. Guidelines for the management of hiatal hernia. Surg Endosc 2013;27(12):4409–4428. DOI: 10.1007/s00464-013-3173-3.

23. O’Rourke RW, Khajanchee YS, Urbach DR, et al. Extended transmediastinal dissection: An alternative to gastroplasty for short esophagus. Arch Surg 2003;138:735–740. DOI: 10.1001/archsurg.138.7.735.

24. Okrainec A, Ferri LE, Feldman LS, et al. Defining the learning curve in laparoscopic paraesophageal hernia repair: A CUSUM analysis. Surg Endosc 2011;25(4):1083–1087. DOI: 10.1007/s00464-010-1321-6.

25. Serag HB, Sweet S, Winchester CC, et al. Update on the epidemiology of gastro-oesophageal reflux disease: A systematic review. Gut 2014;63(6):871–880. DOI: 10.1136/gutjnl-2012-304269.