Philippe J Quilici, MD, Alexander S Tovar, MD, Miranda Boeh, RNNP, Kim Lewan, RNNP. Department of Surgery, Providence Saint Joseph Medical Center, 201 South Buena Vista Street, Suite 425, Burbank, CA 91505, USA..
Large paraesophageal hernias are notoriously difficult to manage via laparoscopy and are associated with a significant recurrence rate. A follow-up series of a novel laparoscopic approach was used to close the diaphragmatic defect in 48 patients diagnosed with large, paraesophageal hernias and gastroesophageal reflux disease symptomatology.
All procedures were performed via laparoscopy. Patients underwent a reduction of the paraesophageal hernia with standard crural closure (when feasible) with a Nissen fundoplication or a Collis-Nissen fundoplication. In all patients, the left hepatic lobe was freed, repositioned, and anchored under and inferior to the gastroesophageal junction, propping the gastroesophageal junction anteriorly. This maneuver is designed to entirely cover and closes the diaphragmatic defect.
Postoperatively, 47 patients did well without notable, unusual complaints. Average length of stay was 2 days. One patient underwent a take-down of the repair 5 days post-op for sepsis of unknown origin. Three patients reported early significant, post-op dysphagia. To date all patients had no recurrence of symptoms or of their paraesophageal hernia.
In selected patients, large paraesophageal hernias can safely be managed via a laparoscopic antireflux procedure with the hepatic shoulder technique. Although no significant long-term follow-up is available, this technique continues to show good early postoperative results and can be used as an alternative to a laparoscopic Mesh reinforced fundoplication or difficult crural closure.