Increased Incidence of Diaphragmatic Herniation after Minimally Invasive Esophagectomy – initial experience in a UK Specialist Unit

David E Messenger, MD, FRCS, Simon M Higgs, MD, FRCS, David F Hewin, MD, FRCS, Vipond N Mark, MD, FRCS, Hugh Barr, MD, FRCS, Simon J Dwerryhouse, MD, FRCS, Martin S Wadley, MD, FRCS. Worcestershire Royal Hospital, Worcester and Gloucestershire Royal Hospital, Gloucester, UK.

 INTRODUCTION

The uptake of minimally invasive esophagectomy (MIE) in the UK has increased dramatically in recent years. Diaphragmatic herniation post-esophagectomy is rare, although some reports suggest that its incidence is increased in patients undergoing MIE as opposed to open surgery. This may be due to a reduction in adhesion formation during the laparoscopic abdominal phase. We aimed to compare the incidence of diaphragmatic herniation following open and MIE in our centre.

METHODS and PROCEDURES

Consecutive patients undergoing esophagectomy for malignant disease between 1996 and 2012 were included. (Specialist Unit and MIE program established 2008). Patient demographics, details of surgery and post-operative complications were collected from patient records and a prospective database. Two-stage Ivor Lewis Esophagectomy was the procedure of choice either open or MIE. In our unit both laparoscopic assisted (LAE) and more recently complete MIE procedures are performed.

RESULTS

During the study period 273 patients (205 open, 68 MIE) underwent esophagectomy. Of the 68 MIEs, 62 (91%) had a laparoscopic assisted procedure with 6 total MIEs. 9 (13.2%) patients developed a diaphragmatic hernia in the MIE group compared with 2 (1.0%) patients in the open group, (p<0.001). 5 patients developed hernias in the early post-operative period (days 2-10), all from the MIE group. Both cases of herniation in the open group occurred following a transhiatal esophagectomy at an interval of 44 and 114 months, respectively. All patients who developed a hernia were symptomatic and required surgical repair. A CT scan of the thorax was used to confirm the diagnosis in 10 patients. Repair of seven hernias was achieved laparoscopically, including two cases in the early post-operative period. Diaphragmatic hernias were repaired using the following techniques: suture apposition of the crura (n=6), mesh repair (n=4) and fixation of the gastrocolic omentum to the undersurface of the anterior abdominal wall as the defect was too large to close (n=1).

CONCLUSIONS

There was a significantly increased incidence of diaphragmatic herniation following MIE compared to open surgery. The reasons for this are unclear and may not be completely explained by the reduction in adhesion formation. Strategies such as fixation of the conduit to the diaphragm and the omentum to the abdominal wall may reduce the incidence of herniation.