Aim: Intra-thoracic stomach (ITS) represents the most extreme form of paraesophageal hernia (PEH). A high rate of recurrences after laparoscopic repair of PEH has prompted the widespread use of mesh for hiatal reinforcement. However mesh placement can have serious complications. We aim to show that mesh is not needed routinely as long as attention is paid to address short esophagus.
Methods: All patients undergoing laparoscopic repair of ITS by a single surgeon from January 2004 thru July 2007 are included. ITS is defined when nearly the entire stomach has herniated above the diaphragm. Objective evaluation for hiatal hernia recurrence was undertaken either by upright esophagram or upper endoscopy at least one year after surgery. Any symptomatic or asymptomatic recurrence was considered a failure.
Results: Forty-five patients underwent laparoscopic repair of ITS during the study period. Twenty-six (58%) were women. The mean age was 71.8 (range 48 to 88). Three (7%) patients required conversion to open including one patient who could not tolerate pneumo-peritoneum. Two conversions were for mediastinal bleeding .Four (9%) patients had mesh used for crus closure. Eleven patients (24%) were deemed to have short esophagus (SE) of which 5 underwent Collis-gastroplasty with fundoplication. Twenty-seven patients had a concomitant anti-reflux procedure performed. A total of 13 (29%) patients (6 with SE) had only sac excision and repair of hiatus defect. Twenty-eight patients had more than one year follow-up. Mean follow-up is 24.1 (range 12 to 43) months. One year follow-up was available in 96% (27/28) of patients; one patient has died in the interim due to unrelated causes. There was two (8%) anatomic failure both had a 1-cm asymptomatic hiatal hernia. All patients report a high degree of satisfaction with surgery (mean score 9.1 on scale of 1 to 10). There was no significant difference in satisfaction scores with/ without mesh use or with/without fundoplication.
Conclusion: The laparoscopic repair of ITS is safe and durable with high patient satisfaction at long term follow-up. The most important things to avoid the recurrence were meticulous dissection and to address the short esophagus. From our study, mesh is not needed routinely to achieve successful repair additionally role of fundoplication needs to be defined.
Program Number: P257