Laparoscopic Paraesophageal Hernia Repair

Educational Objectives

The goal of this program is to improve the treatment of patients with paraesophageal hernias. After hearing and assimilating this program, the clinician will be better able to:

1. Employ appropriate techniques to enhance outcomes in patients undergoing repair of paraesophageal hernias.

Summary

Paraesophageal hernias (PHs): make up 14% of hiatal hernias; principles of repair — reduce hernia; mobilize and excise sac; dissect intrathoracic esophagus completely; close hiatus posteriorly (closing anteriorly inadequate); antireflux procedure recommended in majority of cases; benefit of gastropexy questionable (reduction in incidence of recurrence not found in many studies)

Laparoscopic repair of PH: advantages — superior visualization of hiatus compared with open surgery, lower morbidity rate, shorter hospital stay, and shorter recovery time; disadvantages — in early reports, rate of recurrence higher than with open repair; techniques vary widely; overall rate of recurrence 14% to 15% (for repair of asymptomatic hernias ≈25%)

Techniques of laparoscopic repair: tension-free repair of crura may be achieved by placing mesh (eg, triangular mesh, keyhole technique) or fashioning relaxing incisions; placement of interrupted permanent sutures with pledgets provides non–tension free repair; randomized controlled trials found that reinforcement with mesh reduces incidence of recurrent hernias ≈50%; however, synthetic mesh associated with morbidity (eg, erosion, early dysphagia); complications of mesh more common in early reports; in more recent studies using lightweight mesh, incidence of complications lower; rate of recurrence using biologic mesh similar to primary closure

Speaker’s technique: previously, hiatus closed primarily with interrupted polyester (Ethibond) sutures reinforced with mesh; currently, speaker uses barbed polytetrafluoroethylene (Prolene) sutures without mesh; in first 150 patients, only one symptomatic recurrence found; procedure — insert 5 trocars; position patient in reverse Trendelenburg position; reduce hernia; ligate short gastric vessels to mobilize 33% to 50% of fundus; dissect left crus; insert 32-F lavage tube for fundoplication; dissect and excise hernia sac; free esophagus from all adhesions; dissect right crus; close crura with continuous 2-0 barbed sutures (achieves tension-free closure); perform antireflux procedure (usually “floppy” Nissen fundoplication) using silk sutures (one stitch incorporates esophagus)

Readings

Memon MA et al: Suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia: A meta-analysis and systematic review of randomized controlled trials. Ann Surg 2016 Feb;263(2):258-66; Nguyen D et al: Unidirectional barbed sutures as a novel technique for laparoscopic ventral hernia repair. Surg Endosc 2016 Feb;30(2):764-9; Stadlhuber RJ et al: Mesh complications after prosthetic reinforcement of hiatal closure: a 28-case series. Surg Endosc 2009 Jun;23(6):1219-26.

Disclosures

For this program, the following has been disclosed: Dr. Szomstein reported nothing to disclose. The planning committee reported nothing to disclose. In his lecture, Dr. Szomstein presents information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Szomstein was recorded at Updates in Abdominal Wall Reconstruction, presented by the Cleveland Clinic Foundation Center for Continuing Education and held January 12-14, 2017, in Orlando, FL. For information on upcoming CME activities presented by the Cleveland Clinic Foundation Center for Continuing Education, please visit ccfcme.org. The Audio Digest Foundation thanks the speakers and sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS642401

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.