George H Pfaltzgraff, MD, FACS. Ellsworth Municipal Hospital.
The hypothesis that there could be a minimally invasive, safe operation with few side effects, and few failed hiatal hernia repairs led to the use of a combination of laparoscopic anterior hiatal hernioplasty with the Transoral Incisionless Fundoplication. This was evaluated in a single center, single surgeon study.
Methods and procedures
Since April of 2010, 61 patients with gastroesophageal reflux disease underwent a laparoscopic anterior hiatal hernioplasty and fundoplication using the EsophyX device trans orally. All varieties of hiatal hernia were approached with the exception of the shortened esophagus. Symptoms caused by reflux included heart burn, epigastric pain, uncontrolled emesis, severe chest pain treated unsuccessfully with coronary artery stenting, Barrett’s esophagitis, respiratory compromise from an intrathoracic stomach, volvulus of a partial intrathoracic stomach, failed Nissen Fundoplication, sore throat, sinusitis, and the presence of nighttime oral gastric contents. This is a retrospective review collected from a prospectively maintained data base of a single surgeon in a small rural hospital.
Complications in these 61 patients who represented all types of hiatal hernias and defects, with the exception of a shortened esophagus, included one infection which occurred prior to the use of routine antibiotics (a mediastinal abscess treated successfully with excellent results). There have been no recurrences of an esophageal hiatal defect or evidence of reflux at a median of 21 (range 5-48) months. One elderly patient who was treated because of nighttime reflux insisted postoperatively that he still had a bad taste in his mouth in the morning even though his Barrett’s had healed and he had a Hill grade I gastroesophageal junction. Another patient treated for vague complaints after a previous Nissen Fundoplication continued to have unchanged complaints, but not reflux. All patients were capable of emesis and eructation without difficulty. No patient suffered symptoms that could be attributed to vagal injury.
The results from this study suggest that the combined laparoscopic anterior hiatal repair and Transoral Incisionless Fundoplication can be safely used for all types of esophageal hiatal hernias, excluding the shortened esophagus, with excellent resolution of symptoms of reflux, without recurrent hiatal hernias. The incidence of bloating was not observed. Patients were able to vomit and eructate after this combination of procedures.