Background: Laparoscopic repair of paraesophageal hernias (PEH) has been extensively studied, as has primary and redo fundoplications. However, very little data are published regarding laparoscopic management of recurrent PEH. We sought to evaluate our institution’s experience with laparoscopic repair of recurrent PEH.
Methods: We performed a retrospective review of the Johns Hopkins Medical Institutions’ administrative databases from 1995 to 2009 and identified 655 patients who underwent any hiatal hernia repair. We defined a laparoscopic recurrent PEH repair as a laparoscopic reoperative procedure in which a PEH was the primary indication for the original and the reoperative surgery. Initial PEH repairs, reoperative thoracotomies and laparotomies, and surgeries in which a PEH was repaired as an incidental finding or a secondary goal during an anti-reflux procedure were excluded. Using our strict definition, patient medical records were closely reviewed to identify true laparoscopic recurrent PEH repairs. Age, Sex, and BMI were recorded. Type of operation (laparoscopic vs. thoracotomy vs. laparotomy), type of diaphragm repair, use and type of mesh, and type of fundoplication were recorded in both the original and reoperative procedures, as well as the time interval between the two. Intraoperative findings and post-operative complications were noted as well.
Results: From 1995 to 2009, we identified seven laparoscopic repairs of recurrent PEH. Five (71%) were female. Mean age at time of reoperative surgery was 61 y/o. Mean BMI was 27.4. Time interval between the original and reoperative surgeries ranged from 7 to 324 mos, mean of 87 mos. The mean time interval between the two surgeries was longest (252 mos) in patients who originally underwent a thoracotomy. Of the initial PEH repairs, two (29%) were left thoractomies, five (71%) were laparoscopic. Mesh was used in two (29%) patients (one bioprosthetic and one prosthetic), and all underwent Nissen fundoplication. Of the reoperative surgeries, all were laparoscopic, with one conversion to laparotomy. Mesh (all biosprosthetic) was used in five (71%). All previously performed Nissen fundoplications were found to be intact. The laparoscopic to open laparotomy conversion was secondary to the intraoperative finding of previously placed prosthetic mesh eroding into the posterior esophagus. The difficult dissection and posterior gastroesophageal erosion were managed with a total gastrectomy. Other complications included respiratory in one patient and leaks suspected in two patients on initial postoperative imaging, but not seen on repeat imaging, therefore none required intervention. There were no mortalities.
Conclusion: While the incidence of true recurrent PEH remains under debate and study, their laparoscopic management seems to be a rare occurrence. Most reoperative PEH surgeries can be done laparoscopically with low morbidity and low mortality. As with primary PEH repairs, the role and long term outcome of mesh placement remains uncertain in recurrent PEH repairs.
Program Number: P354