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Recurrent symptomatic paraesophageal hernias (PEHs) can lead to significant morbidity if untreated. Surgical treatment of recurrent PEH can pose a great challenge. Several different surgical options are available and need to be considered on an individual basis. Before embarking on the repair of a recurrent hernia, a thorough work-up needs to be completed. Although recurrent PEHs have traditionally been repaired through an open approach, a minimally invasive approach can be performed by surgeons with extensive experience in minimally invasive esophageal surgery. Repair of recurrent PEH provides excellent patient satisfaction and symptoms resolution. Routine follow-up with surveillance imaging can assist in treating recurrent symptoms.

Tension-free repair remains the most important principle of surgical management of giant paraesophageal hernias. The axial tension is relieved by generous circumferential mobilization of the esophagus in the mediastinum to the level of subcarina. An esophageal lengthening procedure may be necessary for a true short esophagus. The radial tension is managed by mobilizing the left and right diaphragmatic crus. Adjunctive procedures such as pleurotomy or diaphragmatic relaxation incisions may be needed to further reduce the tension on the repair.

Giant paraesophageal hernias can present as an asymptomatic incidentally detected paraesophageal hernia to an emergent gastric volvulus with concern for ischemia. In the acute setting, the preoperative evaluation aims to determine the extent of complications from gastric volvulus. In the elective setting, preoperative testing defines the gastroesophageal anatomy and function to select the optimal operation. Through thoughtful preoperative evaluation, the best operative approach can be tailored to each patient.

Paraesophageal hernias comprise about 5–10% of all hiatal hernias. Majority of patients are asymptomatic while some may present with reflux symptoms, obstruction or bleeding. There are numerous controversies on the indications of surgery, operative approach, hernial sac excision, fundoplication and on the use of a mesh. Methods We present a series of 3 patients with giant paraesophgeal hernia diagnosed in year 2020 in our institution, followed by a literature review. This study aims to assess the indications and effectiveness of laparoscopic paraesophageal hernia repair with routine sac excision, primary crural repair and fundoplication in the treatment of giant paraesophageal hernia. Results There were 3 patients in this study. Their mean age was 49. All patients had type IV hiatal hernia and the mean hernia defect was 8 cm in diameter. Laparoscopic paraesophageal hernia repair, sac excision and anterior 180 degree fundoplication was successfully done for all patients without conversion to open surgery. There was no intraoperative or post-op complications. Mean length of stay post-op was 2 days. At one year follow-up, all patients achieved complete resolution of symptoms without new onset reflux or dysphagia. Conclusion Laparoscopic paraesophageal hernia repair with routine sac excision, primary crural repair and fundoplication is safe and effective in treating giant paraesophageal hernias. Tension free repair is the key to success. A 180-degree anterior partial wrap may be able to reduce the incidence of dysphagia.

Summary Background Paraesophageal hernias (PEH) present with a range of symptoms affecting physical and mental health. This systematic review aims to assess the quality of reporting standards for patients with PEH, identify the most frequently used quality of life (QOL) and symptom severity assessment tools in PEH and to ascertain additional symptoms reported by these patients not captured by these tools. Methods A systematic literature review according to PRISMA protocols was carried out following a literature search of MEDLINE, Embase and Cochrane databases for studies published between January 1960 and May 2020. Published abstracts from conference proceedings were included. Data on QOL tools used and reported symptoms were extracted. Results This review included 220 studies reporting on 28 353 patients. A total of 46 different QOL and symptom severity tools were used across all studies, and 89 different symptoms were reported. The most frequently utilized QOL tool was the Gastro-Esophageal Reflux Disease-Health related quality of life questionnaire symptom severity instrument (47.7%), 57.2% of studies utilized more than 2 QOL tools and ‘dysphagia’ was the most frequently reported symptom, in 55.0% of studies. Notably, respiratory and cardiovascular symptoms, although less common than GI symptoms, were reported and included ‘dyspnea’ reported in 35 studies (15.9%). Conclusions There lacks a QOL assessment tool that captures the range of symptoms associated with PEH. Reporting standards for this cohort must be improved to compare patient outcomes before and after surgery. Further investigations must seek to develop a PEH specific tool, that encompasses the relative importance of symptoms when considering surgical intervention and assessing symptomatic improvement following surgery.

The ideal operative solution to giant paraesophageal hernias involves a complex evaluation of the functional anatomy and the intraoperative assessment of both esophageal length and crural closure tension. The addition of surgical adjuncts such as extended transmediastinal dissection, Collis gastroplasty, and mesh reinforcement are all necessary, on an individualized basis, to address these 2 primary causes of hernia recurrence. We discuss the options available.

Paraesophageal hernias in children are rare, and can occur congenitally or be acquired. Acquired cases most often follow anti-gastroesophageal reflux surgery, or less commonly trauma. In children, elective repair is encouraged at the time of diagnosis to prevent future life-threatening complications.

Introduction: Paraesophageal hernias readily affect the elderly with a median age of presentation between 65 and 75 years. Laparoscopic paraesophageal hernia repair (PEHR) is a technically challeng...

Paraesophageal hernia repair and the use of a mesh to avoid any tension during repair is a controversial issue (1). On one side, due to complications related to those prosthetic materials and, on the other side, about the type of mesh to be used and where they should be placed.

Laparoscopic surgery is considered the standard approach for the treatment of paraesophageal hernias (PEHs). Despite its advantages, this approach is technically demanding with significant limitations and steep learning curve. Robotic has emerged as an acceptable alternative since it has proven to be feasible and safe with a learning curve comparable to the standard laparoscopic approach. The goal of this chapter is to describe our step-by-step technique to robotic assisted paraesophageal hernia repair.

Giant paraesophageal hernias have a surgical indication in case of symptoms. Since twenty years ago robot-assisted repair was incorporated to overcome the limitations of the laparoscopic surgery, and to offer new advantages.To report the experience on repairing giant paraesophageal hernias assisted by robot in a fourth level hospital in Bogotá, Colombia, Shaio Clinic.Retrospective and descriptive study of five cases of giant paraesophageal hernia type III or IV, taken to robotic correction during August 2016 to June 2018. Evaluation of post-surgery outcomes.Five paraesophageal robot-assisted repair were performed. Mean surgical time was 146 minutes, one conversion to open surgery, the average intraoperative bleeding was 100 mL, hospital stay time of 2.2 days. Morbidity, mortality and recurrence percentages in the short time were equal to 0%.Robot-assisted repair of giant paraesophageal hernias, has shown advantages that overcome the limitations of the laparoscopic approach such as dissections in difficult-to-reach angles, increased accuracy, ergonomics, three-dimensional, and closer view of the workspace. In addition, robot-assisted repair promotes better surgical and postoperative outcomes; these advantages have been demonstrated mainly in the repair of giant paraesophageal hernias.Las hernias paraesofágicas gigantes tienen indicación quirúrgica en caso de ser sintomáticas. Hace 20 años se incorporó la reparación asistida por robot debido a las ventajas que ofrece sobre las limitantes de la laparoscopia.Reportar la experiencia en reparación de hernias paraesofágicas gigantes asistida por robot en un hospital de cuarto nivel en Bogotá, Colombia, Fundación Clínica Shaio.Estudio retrospectivo, descriptivo, de cinco casos de hernia paraesofágica gigante tipo III o IV, llevados a corrección robótica, de agosto de 2016 a junio de 2018, con evaluación de los desenlaces posoperatorios.Cinco pacientes fueron sometidos a reparación asistida por robot, el tiempo quirúrgico fue de 146 minutos, se realizó una sola conversión a cirugía abierta, la media de sangrado fue de 100 ml, el tiempo de estancia hospitalaria de 2.2 días, y los porcentajes de morbilidad, mortalidad y recurrencia a 1 año fueron del 0%.La reparación de este tipo de hernias asistida por robot ha mostrado ventajas sobre el abordaje laparoscópico, como realizar disecciones en ángulos de difícil acceso, precisión aumentada, ergonomía y vista tridimensional y más cercana del espacio de trabajo. Además, promueve mejores desenlaces quirúrgicos y posoperatorios, ventajas evidenciadas principalmente en la reparación de hernias paraesofágicas gigantes.

Background The aim of the study is to determine if barium esophagram (BE) alone is sufficient to diagnose esophageal dysmotility when compared to the gold standard, high-resolution manometry (HRM). Methods This is a retrospective review of patients that underwent laparoscopic fundoplication by two surgeons at a single institution from 10/1/2015-6/29/2019. Patients with large paraesophageal hernias and patients without both BE and HRM were excluded. Results Forty-six patients met the inclusion criteria. BE was found to be concordant with HRM for esophageal motility in only 21 patients (46%). Setting HRM as the gold standard, BE had a sensitivity of 14% (95% CI: 5%–35%), specificity of 72% (95% CI: 52%–86%), PPV of 30% (95% CI: 11%–60%), and NPV of 50% (95% CI: 35%–66%). The accuracy was 46%, while a McNemar test showed p = 0.028. Conclusion Traditional BE should not be used in place of HRM for assessing pre-operative motility in patients undergoing anti-reflux surgery.

With growing concern over the side effects of long-term proton pump inhibitor use, the surgical management of reflux disease has recently become increasingly popular, especially with the development of the laparoscopic approach. Anti-reflux surgery and paraesophageal hernia repair require technical expertise. These operations have a known failure rate over time, and many patients will go on to require a subsequent intervention. Patients with development of new symptoms after surgery or worsening symptoms should be evaluated for a revisional operation. The workup of these patients can often guide management and surgical planning and may aid in identifying patients that will respond to medical therapy. Once the decision is made to take the patient to the operating room, reoperative surgery can present challenges with difficult dissection and alterations in anatomy. Essential operative steps should include efforts to restore “normal” anatomy, which can include taking down the fundoplication and cruroplasty, evaluation for a short esophagus, recreating the fundoplication, posterior cruroplasty with or without biologic mesh reinforcement, and intraoperative endoscopy. The following chapter will detail the workup for a patient being evaluated for revisional anti-reflux surgery or a patient with a recurrent paraesophageal hernia, as well as essential operative steps and outcomes.

Prosthetic reinforcement reduces the recurrence rate of large paraesophageal hernias (PEH), but the use of synthetic or biosynthetic mesh in the repair remains controversial. PEH repair has reported recurrence rates of 12% to 42%, and primary repair of PEH by suture closure under tension is at high risk of disruption. Synthetic mesh use in large PEH repair has shown to reduce recurrence but can lead to problems including mesh erosion, ulceration, stricture, and dysphagia. The objective of this study was to examine the long-term safety and efficacy of Strattice biologic mesh, a porcine acellular dermal matrix, in crural reinforcement of laparoscopic large PEH repair. Thirty-five patients with symptomatic PEH (>5 cm) were consented to receive Strattice for PEH repair. Patients were seen in clinic preoperatively, at surgery, and 2 weeks, 6 months, and 12 months postoperatively. Patients were given a standard subjective reflux test at each visit and a 12-month barium swallow X-ray to test for recurrence. Hernia recurrence was documented in 14.3% of cases by the end of the 1-year follow-up. Symptoms improved in 75% to 100% of patients by 6 months, and 33% to 100% of patients were still reporting symptom improvement at 12 months. Strattice mesh in PEH repair results in similar outcomes to other absorbable meshes, and the recurrence rate is within the 12% to 42% range of recurrences reported in studies outside of our institution. The use of Strattice mesh in large PEH repair had results similar to other biomaterial meshes and successfully decreased patients’ symptom scores through surgical intervention.

Background and Objectives: A feared complication of large paraesophageal hernias is incarceration necessitating emergent repair. According to previous studies, patients who require an emergent operation are subject to increased morbidity compared with patients undergoing elective operations. In this study, we detail patients who underwent hernia repair emergently and compare their outcomes with elective patients. Methods: A retrospective analysis was performed of the paraesophageal hernia repair operations between 2010 and 2016. Patients were divided into 2 groups: patients with hernias that were repaired electively and patients with hernias that were repaired emergently. Perioperative complications and follow-up data regarding morbidity, mortality, and recurrence were also recorded. A propensity analysis was used to compare emergent and elective groups. Results: Thirty patients had hernias repaired emergently, and 199 patients underwent elective procedures. Patients undergoing emergent repair were more likely to have a type IV hernia, have a partial gastrectomy or gastrostomy tube insertion as part of their procedure, have a postoperative complication, and have a longer hospital stay. However, propensity analysis was used to demonstrate that when characteristics of the emergent and elective groups were matched, differences in these factors were no longer significant. Having an emergent operation did not increase a patient's risk for recurrence. Conclusion: Patients who had their hernias repaired emergently experienced complications at similar rates as those of elective patients with advanced age or comorbid conditions as demonstrated by the propensity analysis. The authors therefore recommend evaluation of all paraesophageal hernias for elective repair, especially in younger patients who are otherwise good operative candidates.

Acute presentations of paraesophageal hernias such as strangulation, perforation, ulceration, and hemorrhage have been associated with increased morbidity and mortality. Such complications are indications for emergent surgical management, with earlier interventions shown to improve postoperative outcomes. However, surgical repair of complicated paraesophageal hernias remains technically challenging for many surgeons, and options for emergent management remain poorly described in the literature. Depending on clinical stability of the patient and surgeon expertise, surgical options may include use of minimally invasive techniques or life-saving damage control strategies to temporize patients until definitive repair.

Paraesophageal hernias have among the highest recurrence rates of all hernias and represent a technically challenging problem for the surgeon. There is broad heterogeneity in both the type of paraesophageal hernia as well as the options for repair. This chapter will review the evaluation of a patient with a recurrent paraesophageal hernia as well the factors involved in patient selection. We will detail our preferred operative technique in recurrent paraesophageal hernia repair as well as technical considerations. Finally the results of repair are reviewed.

Laparoscopic repair of large paraesophageal hernias has been challenging due to high recurrence rates with primary repair and complications associated with the use of nonabsorbable mesh to reinforce the hiatus. The aim of our study was to evaluate the recurrence rate over time and mesh-related complications using an absorbable polyglactin mesh secured with Bioglue to reinforce the hiatus after laparoscopic repair of large paraesophageal hernias. There were 190 patients who met inclusion criteria from June 2006 to June 2014. Follow-up was routinely performed at 1-year intervals, including endoscopy and/or video esophagram, and the gastroesophageal reflux disease health-related quality of life questionnaire. Mean follow-up was 21 months (3–88). There were no incidences of mesh erosion. Recurrence was detected in 17 patients (15.3%), with a median time to recurrence of 23 months (8–67). Recurrence rate was estimated with the Kaplan-Meier method to be 2.9 ± 1.6 per cent, 11.6 ± 3.7 per cent, 22.4 ± 5.6 per cent, 25.1 ± 6.0 per cent, and 29.5 ± 7.9 per cent at 12, 24, 36, 48, and 60 months, respectively. The mean gastroesophageal reflux disease health-related quality of life was 2 in patients both with and without recurrence. Laparoscopic intrathoracic stomach repair using absorbable polyglactin mesh and Bioglue for crural reinforcement is effective, safe, and durable. The rate of recurrence plateaus over time with the majority of recurrences being small to moderate asymptomatic hernias.

Simultaneously occurring Morgagni hernia and paraesophageal hernia is an extremely rare clinical condition with only six case reports in the English-language literature and only two laparoscopic repair reports. We report a 73-year-old woman with both Morgagni hernia and paraesophageal hernia who underwent successful laparoscopic repair of the hernia defects using transabdominal wall suturing. The laparoscopic operation can provide excellent exposure and repair the hernia defect easily with minimal invasiveness and fewer complications. This case report reported the concurring Morgagni and paraesophageal hernias and validated the feasibility of laparoscopic repair both hernias simultaneously.

The most accepted management for symptomatic paraesophageal hernias (PEHs) is the closure of the hiatal gap associated with an antireflux procedure. When the defect of the hiatus is particularly wide or the consistency of the pillars is weak, a prosthetic mesh may be used to cover the suture cruroplasty. Nevertheless, the use of mesh in PEHs repair is a subject of ongoing debate, due to the local risk of complications that a foreign body located in this area can lead. We present the case of a 77-year-old female who underwent PEH surgery with placement of polypropylene mesh twice. On both occasions, the prosthesis migrated late through the wall of the esophagus and could be removed by endoscopy. We consider that this case is exceptional, not only due to the multiple and late extrusion of the mesh in the lumen of the esophagus but also due to the absence of symptoms that this event caused to the patient.

Hiatal hernia (HH) commonly associated with gastroesophageal reflux disease (GERD) and its incidence is approximately 5 per 1000. About 95% of these are type I hernias of sliding variety that are not commonly associated with serious complications 7 [1]. The remaining 5% can be classified as giant paraesophageal hernias (PEHs) type 3 and 4 and are associated with significant complications 7 [2]. Our understanding of hiatal hernia has evolved over the years. Initially considered an anatomical pathology, our focus has now shifted toward the physiology of the esophagus. The appreciation of the physiological link between HH, GERD, and the related problems has caused a paradigm shift toward management of hiatal hernia. Now, we attempt to restore the physiologic function of the esophagus and lower esophageal sphincter and not just a simple repair aimed at restoring the anatomy of the lower esophageal sphincter (LES). Multiple techniques and there modifications are described in literature for repair of hiatal hernia. In the last two decades, hiatal hernia repair has undergone challenges in terms of newer approaches like tension-free repair, use of prosthetic mesh or new biomaterial, laparoscopic approach and lately NOTES, single-port laparoscopic surgery, or robotic surgery.

Hiatal hernias are currently classified into type I–IV hernias (◘ Fig. 38.1). In type I hernias, also called sliding hernias, the gastroesophageal junction is situated above the diaphragm. They are the most common type of hiatal hernia with 80–85% of all hiatal hernias. Type II–IV hernias are less common and characterized by a paraesophageal involvement. Especially type II hernias are rare and characterized as pure paraesophageal hernias. Type III hernias are a combination of type I and type II hernias, the gastroesophageal junction, and the fundus herniate through the diaphragm. If an intra-abdominal organ other than the stomach herniates, a type IV hernia is present. Surgical treatment in type I hiatal hernia is only indicated for concomitant gastroesophageal reflux disease. Hiatal hernias with paraesophageal involvement should be operated if they are symptomatic because of the risk of progression and the risk for complications such as incarceration. The aim of the surgical therapy is the constant reposition of the hernia sac content and the repair of the hiatus. Hiatal hernia repair can either be performed transabdominally or by transthoracic access with an open or minimally invasive approach. The laparoscopic approach is associated with reduced perioperative morbidity and shorter hospital stay while showing equal symptomatic outcome compared to the open abdominal and the transthoracic approach. The minimally invasive abdominal access is thus the preferred approach for most hiatal hernias. Besides the access, the dissection of the hernia sac, the type of cruroplasty, the use of mesh augmentation, and the addition of a fundoplication are factors that have to be considered for an ideal hiatal hernia repair. The chapter gives an evidence-based overview on the mentioned technical considerations, and recommendations are made according to the SAGES Guidelines and the latest literature (◘ Tables 38.1 and 38.2).

Robot-assisted laparoscopic paraesophageal hernia repair and adjunct procedures are described in this chapter. Specifically, the chapter details indications and guidelines for operation, perioperative management strategies, description of room setup and patient positioning, trocar placement, platform docking and instrumentation, as well as operative techniques for robot-assisted laparoscopic paraesophageal hernia repair and adjunct procedures.

We aim to review the endoscopic evaluation of post-fundoplication anatomy and its role in assessment of fundoplication outcomes and in pre-operative planning for reoperation in failed procedures. There is no universally accepted system for evaluating post-fundoplication anatomy endoscopically. However, multiple reports described the usefulness of post-operative endoscopy as a quality control measure and in the evaluation of complex cases such as repeat procedures and paraesophageal hernias (PEH). Endoscopic evaluation of post-fundoplication anatomy has an important role in assessing the outcomes of operative repair and pre-operative planning for failed fundoplications. Attempts have been made to characterize the appearance of the newly formed gastroesophageal valve after successful repairs and to standardize endoscopic reporting and classification of anatomic descriptions of failed fundoplications. However, there is no consensus. More studies are needed to evaluate the applicability and reproducibility of proposed endoscopic evaluation systems in order for such tools to become widely accepted.

Laparoscopic re-operative paraesophageal hernia repair represents one of the most challenging problems facing modern foregut surgery. The incidence of hiatal hernia increases with advancing age and its overall estimated prevalence is as high as 50%, with larger paraesophageal hernias comprising approximately 5% of that number [1–3]. Thousands of primary laparoscopic paraesophageal hernia repairs are performed annually and will likely increase as the aging population continues to grow in number.

Laparoscopic surgery is considered the standard approach for the treatment of paraesophageal hernias (PEH). Despite its advantages, this approach is technically demanding with a significant learning curve. It is also important to emphasize that some of the complications overlap with but they are different. Although postoperative morbidity and mortality seem to be lower after laparoscopic operations, there are a number of specific complications related to this technique that require cautious analysis. Even though, there is some overlap between gastroesophageal reflux disease (GERD) and PEH the patient population and complications are different. Herein, we describe the most common side effects and complications after PEH.

Robotic master-slave devices can assist surgeons to perform minimally invasive esophageal operations with approaches that have already been demonstrated using laparoscopy and thoracoscopy. Robotic-assisted surgery for benign esophageal disease is described for the treatment of achalasia, epiphrenic diverticula, refractory reflux, paraesophageal hernias, duplication cysts, and benign esophageal masses, such as leiomyomas. Indications and contraindications for robotic surgery in benign esophageal disease should closely approximate the indications for laparoscopic and thoracoscopic procedures. Given the early application of the technology and paucity of clinical evidence, there are currently no procedures for which robotic esophageal surgery is the clinically proven preferred approach.

The management of paraesophageal hernia (PEH) can be challenging due to the lack of consensus regarding indications and principles of operative treatment. In addition, data about the pathophysiology of the hernias are scant. Therefore, the goal of this review is to shed light and describe the classification, pathophysiology, clinical presentation, and indications for treatment of PEHs, and provide an overview of the surgical management and a description of the technical principles of the repair.

Older patients have an increased incidence of paraesophageal hernia (PEH) and can be denied surgical assessment due to the perception of increased complications and mortality. This study examines the influence of age and comorbidities on early complications and other short-term outcomes of PEH repair.From 2000 to 2016, data of surgically treated patients with PEH were prospectively recorded in an Institutional Review Board-approved database. Only patients whose hernia involved over 50% of the stomach were included. Patients were stratified by age (70, 70 to 79, ≥80 years of age) and compared in univariate and multivariate analyses.Overall, 524 patients underwent surgical PEH repair (70: 261 [50%]; 70 to 79: 163 [31%]; ≥80: 100 [19%]). Patients greater than or equal to 80 years of age had higher American Society of Anesthesiologists class, more comorbidities, larger hernias, and higher incidences of type IV PEH and acute presentation. Patients greater than or equal to 80 years of age had more postoperative complications, but not higher grade complications (Clavien-Dindo grade ≥IIIa). Median length of stay was 1 day longer for patients greater than or equal to 80 years of age (5 days versus 4 days for patients70 and 70 to 79 years of age, respectively). Objective, radiologic hernia recurrence at 4.3 months postoperation was 17.3% and was not increased in the greater than or equal to 80 years of age group. After adjustment for comorbidities and other factors, age greater than or equal to 80 years was not a significant factor in predicting severe complications, readmission within 30 days, or early recurrence.PEH repair is safe in physiologically stable patients, irrespective of age. Incidence of complications is higher in older patients, but complication severity and mortality are similar to those of younger patients. Patients with giant PEH should be given the opportunity to review treatments options with an experienced surgeon.

Surgical management of paraesophageal hernias has changed dramatically during the past two decades. Elective laparoscopic paraesophageal hernia repair is now the standard approach to the patient with a symptomatic paraesophageal hernia. The operation is technically challenging and requires numerous intra-operative and peri-operative considerations. Here, we will highlight the key points in the peri-operative and intra-operative management of paraesophageal hernias, emphasizing the operative goals of reduction of the hernia contents, excision of the hernia sac, a tension free repair with complete esophageal mobilization, crural repair, and fundoplication.

Over the past 15 years, laparoscopic repair of primary paraesophageal hernias (PEH) has become the preferred operative approach. Today, more surgeons are approaching recurrent PEHs laparoscopically, though few studies exist on the long-term results of these revisional operations, particularly regarding the incidence of postoperative delayed gastric emptying (DGE).A retrospective review was conducted of all laparoscopic repairs for recurrent PEH done by three surgeons at a single institution from 2003 to 2011. Data collected included age, sex, weight, BMI, pre- and postoperative symptoms, and operative data, but our primary focus was on those patients with pre- and postoperative delayed gastric emptying ultimately requiring operative intervention.Of 284 patients who underwent laparoscopic PEH repair, 91 (32 %) were performed for recurrent PEH. A sleeve gastrectomy was performed in ten of these patients (11 %) for concomitant morbid obesity which were excluded from our study group, leaving 81 study patients. The mean age was 56 years, and mean BMI was 30. All cases were completed laparoscopically; in 45 (56 %) either a partial or complete fundoplication was performed, and in 68 (84 %) a percutaneous gastrostomy tube (PEG) was placed at the time of revision. Sixty-eight patients underwent repair of a first recurrence, of which 8 (12 %) ultimately required a gastric emptying procedure to alleviate symptoms of DGE. There were nine patients who had a second recurrence repaired, and six (66 %) progressed to a gastric emptying procedure. Finally, of the four patients who had a third recurrence repaired, three (75 %) eventually needed a gastric emptying procedure.While the incidence of DGE associated with initial PEH repair is low, DGE is a significantly more common finding in patients requiring reoperation for recurrent PEH. This risk increases significantly with repair of each subsequent recurrence. Our data suggest that DGE should be anticipated and patients counseled of the ramifications of this problem preoperatively. Surgeons performing revisional PEH surgery should preemptively develop protocols for the postoperative management of DGE from the time of operation.

It is the general surgeon who commonly repairs paraesophageal hernias nowadays, and they are repaired laparoscopically, making the performance of thoracotomy relatively rare. Whether to use prosthetic materials to repair the hiatus is still under debate, as is the question of which material to use, if any. We report a case of a 38-year-old man who had a large, incarcerated paraesophageal hernia. He had a past history of extensive abdominal surgery for exomphalos, which rendered any abdominal surgical approach a high-risk procedure. We therefore decided to proceed with thoracotomy and repair of the hiatus with hexamethylene diisocyanate (HMDI) cross-linked porcine dermal collagen. He made a good recovery with no complications.

Congenital paraesophageal hernia is rare in infants and children. This paper describes our experience with seven infants and children with congenital paraesophageal hernia with emphasis on two sisters who presented with unusually large paraesophageal hernias and herniation of most of the stomach resulting in intrathoracic gastric volvolus. The literature on the subject is also reviewed.

Anamnese und klinischer Befund: Eine 74-jahrige Patientin klagte seit mehreren Monaten uber belastungsabhangige, rezidivierende Dyspnoe. Im Rahmen einer erweiterten bildgebenden pulmonalen Diagnostik mittels CT-Thorax war eine monstrose paraosophageale Hiatushernie mit prolabiertem Colon transversum und einem signifikanten Anteil parakolischen Fettgewebes diagnostiziert worden. Die korperliche Untersuchung ergab einen unauffalligen Befund. Untersuchungen: In den Routinelaborkontrollen sowie in der sonographischen Untersuchung des Abdomens fanden sich keine auffalligen Befunde. Endoskopisch zeigten sich regelrechte Verhaltnisse im oberen und unteren Gastrointestinaltrakt. Im Rontgen-Osophagusbreischluck ergab sich ein regelrechter Schluckakt ohne Hinweis auf eine Osophagusfunktionsstorung bei orthotoper Lage von Kardia und Magenfundus. Therapie und Verlauf: Nach sorgfaltiger mediastinaler Adhasiolyse und kompletter Resektion des intrathorakalen Bruchsacks wurden die prolabierten Kolon- und Netzanteile laparoskopisch reponiert. Die Bruchlucke wurde durch eine vordere und hintere Hiatusplastik in Kombination mit einer anterioren 180˚-Semifundoplikatio und Fundophrenikopexie verschlossen. Folgerung: Monstrose paraosophageale Hiatushernien fuhren aufgrund der haufig im Vordergrund stehenden unspezifischen pulmonalen und kardialen Symptomatik zu einer oft langwierigen Diagnosefindung und sollten bei entsprechenden Beschwerden in die Differenzialdiagnostik einer naheliegenden kardialen oder pulmonalen Genese mit einbezogen werden. Die minimal-invasive operative Therapie ist auch hier effizient moglich und bietet neben einem gesteigerten Patientenkomfort aus operativ-technischen Aspekten eine deutlich bessere Visualisierung der intrathorakalen Anteile von Typ-IV-Hiatushernien. History and admission findings: A 74-year-old woman was admitted with a history of recurring dyspnea for several months. During radiological examination of the chest computed tomography demonstrated a giant paraesophageal hernia containing transverse colon with a significant amount of paracolic fat tissue. Physical examination was unremarkable. Investigations: Routine blood tests and abdominal ultrasound were within the normal range. Endoscopy showed a normal upper and lower gastrointestinal tract and barium swallow was normal without any esophageal motor dysfunction. The esophagogastric junction and gastric fundus were below the diaphragm. Treatment and course: Laparoscopy revealed the colonic herniation and mediastinal adhesiolysis, complete resection of the hernia sac and reposition of the intrathoracic migrated transverse colon were undertaken. Hiatal repair was performed by anterior and posterior hiatoplasty and construction of an anterior 180˚ semifundoplication with fundopexy. Conclusion: Patients with giant paraesophageal hernias often present with nonspecific cardiac and respiratory symptoms and the condition is often misdiagnosed. If it is demonstrated, a possible abdominal involvement should be looked for. Minimally invasive surgery is feasible and efficacious in this condition and in addition to being better tolerated by the patient provides a far better visualization of the intrathoracic parts of a type IV hiatal hernia to the surgeon.

Laparoscopic approaches for paraesophageal hernia repair and the use of prosthetic reinforcement materials during crural repair have become standard. However, the search for the optimal prosthetic material and techniques for placement and fixation methods are still controversial and under investigation. The authors aimed to determine the technical feasibility of the use of human acellular dermal matrix for hiatoplasty in a circular fashion during paraesophageal hernia repair in a small series of patients. The short-term outcomes of patients who underwent laparoscopic repair of large paraesophageal hernias with biomesh circular hiatal reinforcement were analyzed. Laparoscopic circular hiatal reinforcement with acellular dermal matrix is feasible and reproducible with no associated short-term morbidity. The acellular dermal matrix mesh is very elastic and has excellent intracorporeal handling characteristics during hiatoplasty.

Paraesophageal hernias are difficult surgical problems that often need repair. Meticulous work-up and surgical technique are required for optimal results. A laparoscopic approach is associated with reduced morbidity and, if combined with the use of biologic mesh, provides relief of symptoms and a durable repair.

Background Historically all paraesophageal hernias were repaired surgically, today intervention is reserved for symptomatic paraesophageal hernias. In this review, we describe the indications for repair and explore the controversies in paraesophageal hernia repair, which include a comparison of open to laparoscopic paraesophageal hernia repair, the necessity of complete sac excision, the routine performance of fundoplication, and the use of mesh for hernia repair. Methods We searched Pubmed for papers published between 1980 and 2015 using the following keywords: hiatal hernias, paraesophageal hernias, regurgitation, dysphagia, gastroesophageal reflux disease, aspiration, GERD, endoscopy, manometry, pH monitoring, proton pump inhibitors, anemia, iron-deficiency anemia, Nissen fundoplication, sac excision, mesh, and mesh repair. Results Indications for paraesophageal hernia repair have changed, and currently symptomatic paraesophageal hernias are recommended for repair. In addition, it is important not to overlook iron-deficiency anemia and pulmonary complaints, which tend to improve with repair. Current practice favors a laparoscopic approach, complete sac excision, primary crural repair with or without use of mesh, and a routine fundoplication.

Background A myriad of operation exist to treat type III paraesophageal hernias (T3PH). How does one choose? Methods A retrospective review of a consecutive series of resident-preformed T3PH repair. Results Three patients with T3PH were operated on during a 6-year period. The presentation of each patient was unique. Three different surgical procedures were used to treat these patients depending on the patient’s condition at presentation, the location of the gastroesophageal junction, and the documentation of reflux. Transabdominal hernia reduction and a modified Hill procedure was used in 1 patient; a transthoracic hernia reduction was supplemented with a either a Belsy-Mark IV fundoplication or a Collis-Nissen gastroplasty in the other 2 patients. Patients were discharged home 7 (3–13) days postoperatively, and at a mean follow-up of 23 (2–60) months, all patients are asymptomatic and without radiographic recurrence. Conclusion Operative selection for T3PH should be flexible depending on the (1) urgency of symptoms, (2) location of the gastroesophageal junction, and (3) evidence for gastroesophageal reflux.

Background Laparoscopic repair of large paraesophageal hernias (LPEH) is technically challenging, and requires advanced laparoscopic skills. We have developed a novel technique for facilitating laparoscopic repair of LPEHs safely and easily, using a Nelaton catheter. Patients and Methods Seven patients with LPEHs were operated on through a laparoscopic approach. During surgery, the left lobe of the liver and right diaphragmatic crus were elevated using a suspended thread covered by a Nelaton catheter. Results All patients were operated on laparoscopically using this technique. No patient required conversion to open method. The median operating time was 205 minutes and the range was from 155 to 295 minutes. No intraoperative or early complications occurred in any patient. Late complications occurred in 2 patients due to a small sliding hernia: a slipped fundoplication in 1 patient, and a gastric ulcer in the other. Conclusions In conclusion, laparoscopic repair of LPEH is a challenging procedure that requires wide experience in laparoscopic gastroesophageal surgery. Further refinement for this operation may be necessary.

Little grade A medical evidence exists to support the use of prosthetic material for hiatal closure. Therefore, the authors compiled and analyzed all the available literature to determine whether the use of prosthetic mesh in hiatoplasty for routine laparoscopic fundoplications (LF) or for the repair of large (5 cm) paraesophageal hernias (PEH) would decrease recurrence.A literature search was performed using an inclusive list of relevant search terms via Medline/PubMed to identify papers (n = 19) describing the use of prosthetic material to repair the crura of patients undergoing laparoscopic PEH reduction, LF, or both.Case series (n = 5), retrospective reviews (n = 6), and prospective randomized (n = 4) and nonrandomized (n = 4) trials were identified. Laparoscopic procedures (n = 1,368) were performed for PEH, gastroesophageal reflux disease (GERD), hiatal hernia, or a combination of the three. Group A (n = 729) had primary suture repair of the crura, and group B (n = 639) had repair with either interposition of mesh to close the hiatus or onlay of prosthetic material after hiatal or crural closure. The use of mesh was associated with fewer recurrences than primary suture repair in both the LF and PEH groups. The mean follow-up period did not differ between the groups (20.7 months for group A vs. 19.2 months for group B). None of the papers cited any instance of prosthetic erosion into the gastrointestinal tract.The current data tend to support the use of prosthetic materials for hiatal repair in both routine LF and the repair of large PEHs. Longer and more stringent follow-up evaluation is necessary to delineate better the safety profile of mesh hiatoplasty. Future randomized trials are needed to confirm that mesh repair is superior to simple crural closure.

A tailored approach to the management of patients who have para-esophageal herniation appears to be the best policy. No one approach can universally apply to this patient population if optimal therapy, quality of life, and overall survival are to be optimized.

Laparoscopic repair of paraesophageal hernias is rapidly replacing the traditional open approach. Regardless of the approach, certain aspects of repairing paraesophageal hernias have proven to be beneficial and others remain controversial. This article addresses the effectiveness of the laparoscopic approach, the accepted and controversial technical aspects of repair, and which patients should undergo surgical correction of the hernia.

The success of laparoscopic fundoplication has extended the use of the laparoscopic approach to treating more difficult situations such as paraesophageal hernias (PEHs) or type IlIl (mixed) hiatal hernia. The results have shown that laparoscopic repair is feasible and safe. However, several series have shown recurrence rates of up to 42% as a result of difficulty in the closure of the hiatal gap. Some authors recommend the use of prosthetic mesh to reinforce the hiatal closure. This review analyses the different techniques proposed to prevent recurrence after laparoscopic repair of PEHs. The information currently available shows that the use of a mesh for hiatal repair is safe and prevents recurrence. However, data on the long-term results are lacking, and infrequent but severe complications may arise. The mesh should be used selectively, and the decision to proceed should be based on clinical experience.

Highlights • This is an extremely rare case of type IV paraesophageal hernia (PEH) with small intestine loops bulging up into the thoracic cavity. • The diagnosis of PEH is challenging and based mostly on the imaging findings. • Symptoms vary from dyspnea, due to lung compression, to diffuse abdominal pain. • In the emergency setting laparotomy should be performed without delay., INTRODUCTION Type IV paraesophageal hernias (PEHs) have been rarely reported in the literature. Transverse colon is the most common viscus to herniate in this category. PRESENTATION OF CASE Herein we present a case with an emergent admission of a 66 year old man with type IV PEH with small intestine into the hernia sac. DISCUSSION The diagnosis of PEHs can be challenging due to their extremely low incidence and the non-specific symptoms and can be easily missed from the initial differential diagnosis. CONCLUSION In this case, the hernia was diagnosed early and managed successfully with an immediate laparotomy.

The approach to repair of paraesophageal hernias (PEHs) is controversial. Recent data suggest that mesh repair leads to recurrence rates similar to non-mesh approaches, while subjecting patients to mesh-associated complications. Routine fundoplication during PEH repair has been favored despite significant dysphagia rates. We present our multicenter prospective data on laparoscopic PEH repairs using a modified Boerema anterior gastropexy without fundoplication.We prospectively followed patients after modified Boerema PEH repair at three institutions. Patient demographics, perioperative data, and postoperative outcomes were evaluated. Subjective and objective outcomes were assessed via clinical assessment, follow-up questioning, endoscopy, and radiographic swallow studies.A total of 101 patients were followed a mean of 10.8 (median, 12) months. We encountered 9 (8.9%) intraoperative complications and 13 (12.9%) postoperative complications. There was no mortality. Reflux symptoms were absent in 71 patients (70.3%) postoperatively. Of the remaining subjects, 8 (7.9%) had mild intermittent reflux without the need for proton pump inhibitors (PPI), 12 (11.9%) had moderate reflux necessitating PPI as needed, and 10 (9.9%) had reflux requiring daily PPI. Our recurrence rate, assessed at postoperative endoscopy/barium swallow, was 16.8%. Of these, 10 (9.9%) were small segmental recurrences and 7 (6.9%) were large recurrences.Herein, we demonstrate a favorable recurrence rate while avoiding the potential major complications associated with mesh hiatoplasty. Our data tend to support a tailored approach to incorporation of fundoplication during PEH repair. Postoperative acid reflux was absent in most of our patients, and pharmacotherapy alone was sufficient for those experiencing reflux symptoms.

Background: Paraesophageal hernias (PEHs) have protean clinical manifestations, and a variety of surgical approaches may be appropriate. We report both surgical and quality-of-life (QoL) outcomes for PEH repairs. Methods: All patients undergoing elective repair of PEHs were evaluated preoperatively for symptoms and the radiologic appearance of the PEH. In addition, patients undergoing elective repair completed the SF-36, a generic QoL instrument, preoperatively and postoperatively. Short-term postoperative complications were recorded. Symptomatic outcomes and QoL outcomes were assessed. Results: Over a 50-month period, 44 PEH repairs were completed. 3 patients represented emergently – 2 with gastric ischemia, 1 with frank gastric necrosis. The most common presenting symptoms were heartburn (48%), chest pain (27%), abdominal pain (20%), regurgitation (20%), dysphagia (18%), and microcytic anemia (18%). Only 4 patients (9%) were truly asymptomatic. 31 repairs were attempted laparoscopically, 5 were converted to open procedures. There were no gastric or esophageal perforations. 91% of patients had resolution of preoperative symptoms. The only death was in a patient with gastric necrosis. 5 of 8 patients treated by crural repair without fundoplication developed postoperative heartburn. Patients treated laparoscopically had superior QoL scores than patients treated by open surgery in the domains of physical functioning (90 vs. 65), role-physical (100 vs. 0), role-emotional (100 vs. 66.7), vitality (80 vs. 55), and social functioning (100 vs. 75). However, there were 3 symptomatic recurrences in the laparoscopic group (11.5%), all in patients with large, type-III hiatal hernias. Conclusions: PEH is a potentially life-threatening disease. Although most can be repaired laparoscopically, specific principles must be individualized to each patient to minimize complications and recurrences. A fundoplication should be added to all repairs. Laparoscopic repairs can produce superior QoL results: however, patients with large, type-III hernias may not be appropriate candidates for laparoscopic repair.