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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
Department of Cardiothoracic Surgery
Speaker/Education: Intuitive Surgical
Department of Cardiothoracic Surgery
Types of Hiatal Hernias
Type I
Type II
Type III
Organoaxial volvulus
Department of Cardiothoracic Surgery
Typical Esophagram of Giant PEHIntra-
thoracic
Stomach
Department of Cardiothoracic Surgery
Clinical Presentation
• Asymptomatic
– Air-fluid level on CXR
• Pain
• Postprandial fullness
• Nausea
• Regurgitation
• Anemia
• Emergent
Department of Cardiothoracic Surgery
Evaluation
• Endoscopy
• Barium radiography
• Manometry?
• Computed Tomography?
• Acute Setting
– Laboratory (acid-base/electrolyte derangements, sepsis)
Department of Cardiothoracic Surgery
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
Department of Cardiothoracic Surgery
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.
Department of Cardiothoracic Surgery
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
Department of Cardiothoracic Surgery
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
Department of Cardiothoracic Surgery
Thoracic Approach
• Able to mobilize more esophagus
• Avoid the need for Collis gastroplasty
Department of Cardiothoracic Surgery
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
Department of Cardiothoracic Surgery
• 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
Department of Cardiothoracic Surgery
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
Department of Cardiothoracic Surgery
Laparoscopic “Hand over Hand” Reduction
of Intrathoracic Stomach
Atraumatic Reduction of Stomach
Department of Cardiothoracic Surgery
Laparoscopic Sac Dissection and Excision
Hiatal opening
Hernia sac
Department of Cardiothoracic Surgery
Assessment of Esophageal LengthCardia location
Department of Cardiothoracic Surgery
Esophageal Lengthening
May not be required with
good mobilization and
high mediastinal
dissection
Department of Cardiothoracic Surgery
Fundoplication and Crural Repair
Department of Cardiothoracic Surgery
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
GPEH: Initial View
Department of Cardiothoracic Surgery
GPEH: Initial Sac Retraction
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
Department of Cardiothoracic Surgery
GPEH: Initial Sac Dissection
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
Department of Cardiothoracic Surgery
GPEH: Mediastinal Dissection
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
Department of Cardiothoracic Surgery
GPEH: Pleural Rent Closure
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
Department of Cardiothoracic Surgery
GPEH: Mediastinal Dissection
Karush & Sarkaria. Op Tech in CV and Thoracic Surgery 2014
Department of Cardiothoracic Surgery
Collis Nissen
Department of Cardiothoracic Surgery
Collis-Nissen – Robotic Stapler3:00; 6:00; 7:20
Department of Cardiothoracic Surgery
Thank You
Inderpal S. Sarkaria, MD
Vice Chairman, Clinical Affairs
Director, Robotic Thoracic Surgery
Co-Director, Esophageal & Lung Surgery Institute
Department of Cardiothoracic Surgery
University of Pittsburgh Medical Center