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