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Ciaran O’Hare
A Selective Approach to Type II / III
(Paraesophageal) Hiatal Hernia
Ciaran M. O’Hare FRCSI FACS
Associate Professor OUHSC
Chief of Surgery VAMC
Oklahoma City.
Sept 29th 2005
Ciaran O’Hare
Para-esophageal Hernia
ANATOMY
95%
1%
4%
Ciaran O’Hare
Para-esophageal Hernia
Type II
ANATOMY
Type III
Type IV
Ciaran O’Hare
Para-esophageal Hernia
Aetiology : Type II
Esophago-phrenic ligament
(Type II)
Remains strong posteriorly
Sac is attenuated in ant.
and lat. portions Ciaran O’Hare
Levels Of Evidence
Ciaran O’Hare
Levels Of Evidence
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Levels Of Evidence
Ciaran O’Hare
Para-esophageal Hernia
Symptoms
• Asymptomatic
• Reflux Type Symptoms
• Related to Intrathoracic Stomach
•
(Obstructive + Ischemic)
Acute / Emergent
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Para-esophageal Hernia
Diagnosis
Fluid Level
On CXR
Barium
Meal
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Para-esophageal Hernia
Surgery :
2001-3
• Elective (Asymptomatic, Minimal)
87%
• Acute (Gastric Obstruction or Ischemia)
10%
• Emergent (Gastric Volvulus or Gangrene) 3%
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Para-esophageal Hernia
Principles of Repair
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Reduce Hernia
Excise Sac
(Lengthen Esophagus)
Repair Crura
Gastropexy
Fundoplication
Post-op CXR
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Para-esophageal Hernia
Methods of Repair
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Through Left Chest
better hiatal access, with ‘short’ esophagus, in fat males vs morbidity
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Via Abdomen
quicker, simple gastropexy in emergencies vs hiatus can be difficult
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Laparoscopic
Less morbid vs difficult (R side and sac excision), greater recurrence
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Para-esophageal Hernia
Closing the Large Hiatus
Create a relaxing incision,
then close with PTFE
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Para-esophageal Hernia
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Para-esophageal Hernia
As always, when
data are scarce,
opinions are
strongly held!
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Para-esophageal Hernia
Levels Of Evidence
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Para-esophageal Hernia
Controversies
“The sac must be completely excised”
Acts as a tether promoting recurrence
Interferes with esophageal mobilization
Can promote a post-op fluid collection
Ciaran O’Hare
Para-esophageal Hernia
Controversies
“The sac must be completely excised”
True!
Meta-analysis, Case series
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Para-esophageal Hernia
Controversies
“Fundoplication must always be performed”
Most have some degree of reflux
Compression by stomach prevents pre-op evaluation
Esophageal mobilization predisposes to reflux
Ciaran O’Hare
Para-esophageal Hernia
Controversies
“Fundoplication must always be performed”
Probably true
Case series, Expert Opinion
(Best Available Evidence)
Ciaran O’Hare
Para-esophageal Hernia
Controversies
“Laparoscopic (Open, Thoracic) repair is the preferred
method”
Unproven
No controlled studies
Laparoscopy associated with greater
(asymptomatic) post-op reflux
Ciaran O’Hare
Para-esophageal Hernia
Controversies
“All Paraesophageal Hernias must be repaired”
Hill 1973 – Because 30% will need emergency surgery,
with a 40% mortality.
Also stated by Nyus in “HERNIA” 1964
Quoted in virtually every other paper on the subject till
2000
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Para-esophageal Hernia
• Only 29 patients
• Uncontrolled retrospective
• Some were watched for 20 yrs
• 6/10 – successfully decompressed
• 4/10 died – 2 before surgery
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Para-esophageal Hernia
“All Paraesophageal Hernias must be
repaired…… NO!”
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Degree of herniation varies at any one
time
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Most (90%) of acute presentations can be
decompressed by NG
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Modern worst case operative mortality is
15%
Ciaran O’Hare
Para-esophageal Hernia
“All Paraesophageal Hernias must be
repaired…… NO!”
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Allen 1993 – 1 gastric strangulation/245 pt-yrs
(type IV)
Treacy – 1987
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Hashemi 2000 – 1/54 pts with emergency
surgery
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Pellegrini – 1/45 emergency surgery
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Para-esophageal Hernia
Minimally Symptomatic Patients
5m patient computer model based on clinical databases
Entered modern data for symptom progression, mortality
(emergency and elective)
Compared mandatory surgery vs watchful waiting (with risk
of gangrene) and surgery for symptom progression
But no similar study on the strategy for moderately
symptomatic patients
Ciaran O’Hare
Para-esophageal Hernia
Minimally Symptomatic Patients
Annual risk of needing
emergency surgery is ~ 1.5%
Comparing morb. / mort. of
operating on everyone vs a
strategy of operating
emergently, only 1 / 5 of 65 yr
old, and 1 / 10 of 85 yr olds
would benefit
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Para-esophageal Hernia
So what’s a fellow to do?
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Para-esophageal Hernia
Minimally Symptomatic Patients
Recommendations
- Watch for symptoms showing significant
episodes of gastric obstruction or ischemia
- Even then , carefully weigh the risk v benefit of elective surgery, given
that emergent surgery remains unusual, and survival is 85%
- Difficult hiatal repairs, or with “short” esophagus,
may be best approached trans –thoracic
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Para-esophageal Hernia
Symptomatic Patients
Recommendations
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One would assume that the risk of an emergent event would be
greater, though there is no data
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Perhaps the subset of patients with occasional gastric obstructive
symptoms could be watched, while those with gastric ischemis symptoms
(ulcers, anemia) should be electively operated on
Assess individually and carefully weigh the risk v benefit of
elective surgery
Ciaran O’Hare
Para-esophageal Hernia
Any Questions?
Ciaran O’Hare