Laparoscopic Antireflux Procedures With Hepatic Shoulder Technique for the Surgical Management of Large Paraesophageal Hernias and Refractory Gastroesophageal Reflux Disease

Philippe J Quilici, MD FACS, Carie Mcvay, MD, Alexander Tovar, MD. Dept. of Surgery, Providence St. Joseph Medical Center, Burbank CA

Background:  A novel laparoscopic approach to manage patients diagnosed with large, paraesophageal hernias was initially reported in 2009 and gastroesophageal reflux disease [GERD} symptomatology was presented in 2009. This technique was later used in patients with refractory GERD. A larger series of these cases is now presented.

Methods:  All procedures were performed via laparoscopy. 39 patients underwent a reduction of the paraesophageal hernia with a Nissen fundoplication and two with Collis-Nissen fundoplication. Standard crural closure was performed over a #60 Fr Bougie in 34 patients, and five patients did not undergo a cruroplasty. 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 entirely covers and closes the diaphragmatic defect.

Results:  Postoperatively, all patients did well without notable, unusual complaints. Average length of stay was 1.9 days. One patient was rexplored for possible intra-abdominal sepsis and had a negative exploration. The longest follow-up was 4.2 years. To date, all patients had no recurrence of symptoms or of their paraesophageal hernia.

Conclusion:  In selected patients, large paraesophageal hernias and patients with refractory GERD can safely be managed via a laparoscopic antireflux procedure with the hepatic shoulder technique. Although no long-term follow-up is available, this technique continues to show solid postoperative results and may be used as an alternative to a laparoscopic Mesh reinforced fundoplication or difficult crural closure. 

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