paraesophageal hernia - web-duke-shares-01.oit.duke.edu · –sac excision –collis lengthening...

Department of Cardiothoracic Surgery

Paraesophageal Hernia

Inderpal (Netu) S. Sarkaria, M.D.

Vice Chairman, Clinical Affairs

Director, Robotic Thoracic Surgery

Co-Director, Esophageal and Lung Surgery Institute


Speaker/Education: Intuitive Surgical


Types of Hiatal Hernias

Type I

Type II

Type III

Organoaxial volvulus


Typical Esophagram of Giant PEHIntra-

thoracic

Stomach


Clinical Presentation

• Asymptomatic

– Air-fluid level on CXR

• Pain

• Postprandial fullness

• Nausea

• Regurgitation

• Anemia

• Emergent


Evaluation

• Endoscopy

• Barium radiography

• Manometry?

• Computed Tomography?

• Acute Setting

– Laboratory (acid-base/electrolyte derangements, sepsis)


Acutely symptomatic patients (toxic) require open surgery

• Laparotomy if there is no evidence of chest contamination

• Left thoracotomy if there is evidence of gastric necrosis with chest contamination


Natural History of Giant Hernia

• PEH patients followed for a decade

– 21% presented with strangulation

– Mortality of emergency repair (17%)

– Mortality with elective repair (<5%)

• All patients with giant HH should be repaired

Skinner DB, Belsey RH; J Thorac Cardiovasc Surg. 1967 Jan;53(1):33.


Surgical Principles• Re-establish normal anatomy!

• Atraumatic hernia reduction

• Obtain tension free intra-abdominal esophageal length– Complete excision of hernia sac

– High mediastinal dissection

– Clear anatomic confirmation of GEJ - Esophageal fat pad dissection

• Crural preservation– Atraumatic handling and dissection – preserve the peritoneal lining

• Vagal preservation

• Tension free crural repair– Mobilization of crura

– Suture reinforcement? Pledgets?

– Crural reinforcement/reconstruction? Mesh?

– Esophageal lengthening? Collis?

– Decrease diaphragmatic tension? Decrease intraperitoneal pressure? Induce pneumothorax?

• Gastrofundoplication


Mediastinal Dissection

• Many structures in confined space

– Inferior pulmonary vein

– Azygous vein

– Right atrium

– Airway (right and left mainstem, carina)

– Pleural spaces

– Aorta

– IVC

• Difficult visualization augments the problem


Thoracic Approach

• Able to mobilize more esophagus

• Avoid the need for Collis gastroplasty


Maziak and Pearson. Open Repair of Giant PEH with Collis Gastroplasty and Belsey. Annals Surgery 1998

• 94 patients with intra-thoracic stomach (type III) operated upon over a 20 year period

• Operative approach

– Left thoracotomy

– Sac excision

– Collis lengthening procedure for shortened esophagus

– No deaths, 1% leak rate

• 91% with good results, 9% with fair results

• At a mean follow-up of 10 years only 2 re-operations required

• Sets the gold-standard for outcomes


• 10-year retrospective, Belsey vs Laparoscopic

• 118 Belsey matched 1:1 (year, gender, age)

• Recurrence similar: 8.4% vs 16.1%

– Wedge gastroplasty protective of recurrence

• Esophageal leak higher with Nissen: 0% v 6.8%

• Higher reoperation with Nissen: 2.5% v 9.3%

• GERD HRQL similar

• Single surgeon vs multiple surgeons


UPMC GPEH Experience

• 662 patients

• 1997-2008

• Median age 70 (range 19-92)

• 30 day mortality 1.7% (11 patients)

• Quality of Life

– 90% good to excellent results

• Reoperation 3.2% (21)

• Compatible with “gold-standard” open series

Luketich et al. Outcomes after a decade of laparoscopic giant paraesophageal hernia repair. JTCVS 2010


Laparoscopic “Hand over Hand” Reduction

of Intrathoracic Stomach

Atraumatic Reduction of Stomach


Laparoscopic Sac Dissection and Excision

Hiatal opening

Hernia sac


Assessment of Esophageal LengthCardia location


Esophageal Lengthening

May not be required with

good mobilization and

high mediastinal

dissection


Fundoplication and Crural Repair


Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014

GPEH: Initial View


GPEH: Initial Sac Retraction



GPEH: Initial Sac Dissection



GPEH: Mediastinal Dissection



GPEH: Pleural Rent Closure



GPEH: Mediastinal Dissection



Collis Nissen


Collis-Nissen – Robotic Stapler3:00; 6:00; 7:20


Thank You

Inderpal S. Sarkaria, MD

Vice Chairman, Clinical Affairs

Director, Robotic Thoracic Surgery

Co-Director, Esophageal & Lung Surgery Institute


University of Pittsburgh Medical Center

paraesophageal hernia - web-duke-shares-01.oit.duke.edu · –sac excision –collis lengthening...

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