The Giant Paraesophageal Hiatal Hernias. a New Definition and a New Management


Introduction: Over the past decade, yet challenging, laparoscopic surgery became the standard approach for the repair of paraesophageal hiatal hernias (PEH). The giant PEH is defined in the literature according to the size of the hernia sac. Although the size of the hiatal defect is the most important variable in the equation it has not been studied. The author also hypothesized that anterior mesh bridging carries less erosion

Materials and Methods: Thirty one patients, 15 males (48.4%) males and 16 (51.6%) female, presented with giant PEH. Mean age was 65.6 + 14.1 years. Main symptoms were bloating, chest pain and postprandial discomfort, GERD in 15 (48.4%) and 1 (3.2%) patient had recurrent pneumonias. The Da Vinci was used in 30 patients (96.8%) while one patient (3.2%) was repaired through laparotomy. Vertical and horizontal dimensions of the defect were measured in all patients (100%) and the surface area (cm²) was calculated. Hernia sacs were excised. No-tension crural repair was always attempted. Posterior bridging mesh was performed in the first 2 (0.6%) patients of this series. A novel anterior mesh placement was used in 12 (38.7%) repairs with/without crural repair. Primary posterior crural repair and mesh overlay performed in 15 (48.4%) defects. One patient had 2 meshes placed anterior and posterior to the esophagus. Nissen Fundoplication in 27 (87%) and Toupet in 3 (0.1%) and gastropexy in one patient. Leigh-Collis gastroplasty was required in one patient.

Results: Mean operative time was 142.2 + 42.3 minutes. No mortality. Mean surface area of the defect was 37.5 + 14.9 cm2. Postoperative pneumonia in one patient. The mean hospital stay was 3.4 + 6 days. The length of follow up is 42.8 + 145.3 months. One of the posterior bridging patients developed mesh erosion of the esophagus. Patient rejected surgery. Six (50%) of the anteriorly placed mesh had upper endoscopy with no mesh erosions. Seven patients (22.6%) developed temporary early postoperative dysphagia. One patient persisted to esophageal stricture which responded to dilation. Barium swallow was performed in 12 (38.7%) patients and showed a small sliding hernia in the gastropexy patient. All patients were reported improvement of their preoperative symptoms.

Table 1: Hiatal defect size
Mesh PlacementMean Surface area (cm2)Min Surface area (cm2)Max Surface area (cm2)Defect height (cm)Defect Width (cm)
Anteriorly50.3 + 6.535.9657.57.5 + 0.76.8 + 0.9
Posteriorly27.1 + 11.51256.85.6 + 0.94.7 + 1.7

Conclusion: Mesh bridging may be essential in the repair of the giant PEH with surface area of 40cm2 or greater. The author suggests this modification to the hiatal hernia classification: Type I: Sliding hiatal hernia (SHH), Type II: Small Paraesophageal hernia (sPEH), Type III: Mixed hernia amenable to primary crural repair (MHH) and Type IV: Giant Mixed hernia not amenable to primary crural repair (GMHH). The anterior placement of the mesh is promising in the surgical treatment of Type IV MHHb.

Session: Poster
Program Number: P301
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