Laparoscopic Repair of Esophageal Hiatal Hernia

This study was to appraise safety and feasibility of laparoscopic approach and investigate the clinical effects of laparoscopic tension-free repair of esophageal hiatal hernia using mesh. From August 2006 to July 2009, 24 patients with esophageal hiatal hernia underwent laparoscopic repair. Twenty-three patients received laparoscopic tension-free repair using mesh, at the same time, Toupet or Dor partial fundoplication was performed. One patient was converted to open surgery. The average operating time was 90 min （70-210 min） and the blood loss was between 10-110 mL. There was no death. The mean postoperative hospital stay was 5 days （3-30 days）. During a follow-up period of 12-20 months （mean 15 months）, there was no recurrence of the hernia, and no complication with use of mesh.The present study suggested that laparoscopic approach was secure and minimally invasive operation for esophageal hiatal hernia and the use of mesh could reduce recurrence rate.

Long-term outcome of laparoscopic Nissen-Rossetti fundoplication versus Thal fundoplication in children with esophageal hiatal hernia: a retrospective report from two children's medical centers in Shanghai

Background: This study was undertaken to investigatethe intraoperative and postoperative complications,efficacy and outcome of two laparoscopic fundoplicationsfor the treatment of esophageal hiatal hernia in children.Methods: To find a rational procedure, we performeda retrospective analysis of 136 children with esophagealhiatal hernia who underwent laparoscopic Nissen-Rossettior Thal fundoplication at two children's hospitals inShanghai over 13 years. The median follow-up time of thechildren was 42 months (range: 1-138 months). Their agevaried from 1 month to 11 years (median: 18.6 months).Results: All the children underwent laparoscopicfundoplications (72 cases of Nissen-Rossetti and 60 casesof Thal fundoplication) and 4 children converted to opensurgery. The mean age of the children at the time ofoperation was 1.6±1.9 years, and the mean weight was9.1±5.6 kg. Gastroesophageal refl ux was signifi cantly moresevere after a Thal fundoplication (P=0.003) and slightesophageal stenosis was signifi cant after a Nissen-Rossettifundoplication (P=0.02). The recurrent rate of hiatal herniawas 2.8% (2/72) after Nissen-Rossetti fundoplication incontrast to 5% (3/60) after Thal fundoplication. No deathoccurred after surgery.Conclusions: There was no statistical difference ofrecurrence between laparoscopic Nissen-Rossetti and Thalfundoplication in the long-term outcomes. The rate of slightdysphagia was higher in the Nissen-Rossetti group. TheThal group had a significantly higher recurrence rate ofgastroesophageal reflux. There still exited learning curvefor this procedure. The incidence rate of complications issignifi cantly related to the profi ciency of pediatric surgeon.

Impact of minimally invasive surgery on the treatment of benign esophageal disorders

Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.