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Paraesophageal hernia repair pearls and pitfalls: early recurrence and how to avoid it.

L. Renee Hilton, MD1, Andrew J Duffy, MD, FACS2, Kurt E Roberts, MD, FACS2. 1Augusta University, 2Yale University

Early recurrence of paraesophageal hernias following repair is an infrequent complication but can result in significant morbidity or even mortality when it occurs. When an early complication arises it is important to be able to recognize the signs and expeditiously manage the complication to avoid further complications. In this case report we discuss the management of an early recurrence of a paraesophageal hernia as well as some technical pearls to help avoid the pitfall of early recurrence.

A 77 year old female presented to clinic with 1 year of worsening intermittent positional heartburn and shortness of breath.  She had no other relevant past medical or surgical history.  A CT scan showed a large Type III paraesophageal hernia with gastric volvulus.   She underwent a laparoscopic paraesophageal hernia repair without complications until post-operative day 2 when she began having severe chest pain, shortness of breath, tachycardia, and a leukocytosis.  CT scan revealed that she had an early recurrence of her paraesophageal hernia with gastric volvulus and likely ischemia. We took her to the operating room for laparoscopic exploration.  Intraoperatively, we found her entire stomach in the mediastinum, and it appeared to also be herniating through a hole in the left pleura. She had necrosis of the majority of the greater curve and fundoplication with perforation; intraoperative endoscopy confirmed transmural necrosis. We resected the necrotic area in a “sleeve-like” approach using our endoscope as a bougie. We then performed a gastropexy and inserted a 24 French G-tube into the remaining antrum to help keep the stomach in the abdominal cavity.  The patient did well post-operatively.  She was eventually able to be advanced to a pureed diet and was discharged to a rehabilitation facility. 

Factors which can lead to early recurrence are often technical errors and can usually be avoided by using proper technique. Inadequate esophageal mobilization leading to shortened intra-abdominal length or tension on the crural repair are two technical pitfalls to be wary of when repairing large hiatal hernias. Key operative steps for paraesophageal hernia repair include circumferential reduction and disconnection of the hernia sac from the crura, circumferential mobilization of the esophagus to achieve adequate intra-abdominal esophageal length with return of the gastroesophageal junction to an infradiaphragmatic position, crural closure, and an antireflux operation with the fundoplication anchored to esophageal muscle.  By following these key steps, the pitfall of early recurrence can often be avoided.  

 

 


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 88006

Program Number: V062

Presentation Session: Thursday Exhibit Hall Theater (Non CME)

Presentation Type: EHVideo

41

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