Laparoscopic
Paraesophageal Hiatal
Hernia Repair and
Fundoplication
Lawrence Way, MD
Paraesophageal HH: The Issues
Anatomy.
 Natural history.
 Symptoms and syndromes.
 Indications for operation.
 The operation:
– How often is there a short esophagus
– How to deal with the sac
– How should we close the hiatal opening
– Should a fundoplication be included
– Prevention of reherniation

Patient #1: 69 y.o. woman
Heartburn x15 y. PPIs
monitoring.
relief. UGI: PEH. No pH
Types I, II, III, IV: Anatomy
I
Sliding hiatal hernia
II
Pure paraesophageal HH; GEJ in the
normal position.
Mixed paraesophageal
IV is III plus another organ herniated
III, IV
The pocket (sack) develops first to the left of the esophagus, which
allows the fundus to herniate first. The sack then enlarges anterior
to the esophagus, so the body of the stomach eventually rolls
upward (volvulus) as it enters the chest anterior to the fundus and
esophagus.
Paraesophageal Hiatal Hernia
Type II
Fundus in the
chest; GEJ in
the abdomen
Type III
Fundus and
GEJ in the
chest
Type III
Entire
stomach and
GEJ in the
chest.
Type III
Fundus returns to
the abdomen;
antrum still in the
chest
The distinction between II and III is more theoretical than real. Actually,
whenever there is a paraesophageal component, the GEJ usually moves
cephalad with the fundus (ie, they all are type III). The distinction between
these types on radiographs is unreliable. The notion that Type III is
commonly associated with a “short esophagus” is also untrue.
Paraesophageal HH: The Issues
Anatomy.
 Natural history.
 Symptoms and syndromes.
 Indications for operation.
 The operation:
– How often is there a short esophagus
– How to deal with the sac
– How should we close the hiatal opening
– Should a fundoplication be included
– Prevention of reherniation

Natural History
Textbooks in the past tended to follow
Ronald Belsey, who in the early 1980’s
claimed that 25% of untreated pts. with
paraesophageal HH would end up with
incarceration and serious complications.
 For awhile standard practice was to
recommend prophylactic repair.
 Experience, however, led to a pull back:
the predicted disasters weren’t evident.

Paraesophageal Hernias: Operation or
Observation? Stylopoulos N, Rattner D. Ann
Surg 2002;236:492.
WW compared with ELHR using all data available in the literature.
Mortality rate of ELHR
1.4%
Chances of Sx with WW
1.1%/y
ELHR vs WW (pts >65)
Decrease 0.13
QALYs
ELHR would be more beneficial than WW in less
than one in five patients. In other words, an
operation is not indicated for asymptomatic or
minimally symptomatic patients.
Paraesophageal HH: The Issues
Anatomy.
 Natural history.
 Symptoms and syndromes.
 Indications for operation.
 The operation:
– How often is there a short esophagus
– How to deal with the sac
– How should we close the hiatal opening
– Should a fundoplication be included
– Prevention of reherniation

Clinical Manifestations
Reflux: heartburn, regurgitation,
coughing, etc.
 Entrapment: pain; perforation (rare).
 Obstructive: dysphagia; bleeding from
gastric stasis; dyspnea.

In the face of symptoms, we often do not order pH
monitoring, because surgery is indicated anyway, a
fundoplication is routine, and the test is often unreliable
because the esophagus and stomach are distorted.
Paraesophageal HH: The Issues
Anatomy.
 Natural history.
 Symptoms and syndromes.
 Indications for operation.
 The operation:
– How often is there a short esophagus
– How to deal with the sac
– How should we close the hiatal opening
– Should a fundoplication be included
– Prevention of reherniation

UCSF Experience: PEH
1993-2002
Total patients: lap repair of
PEH
105 patients
Age
69 years
Women
48%
Late follow-up (pts located)
67 patients
360° wrap
42 (63%)
240° wrap
24 (36%)
Ant gastropexy
1
Results
Late UGI series
57 patients (77%)
Two wraps axial slip
Two wraps small PEH
Reoperation
6 patients (9%)
Esophageal perf: one
Erosion of mesh: one
Reflux: 4, all partial wraps
Results
Late UGI series
57 patients (77%)
None of these four
had reflux or other sx
Two wraps axial slip
Two wraps small PEH
Reoperation
6 patients (9%)
Esophageal perf: one
Erosion of mesh: one
Reflux: 4, all partial wraps
None of these four
had hernias
Comparison of Mesh vs No Mesh
Repair
Nineteen articles
1368 patients
Johnson JM, et al. Surg Endosc
2006;20:362
Operations
Recurrences
729 No Mesh
78 (11%)
639 Mesh
12 (2%)
Randomized Mesh Trial
Biologic Prosthesis Reduces Recurrence After Laparoscopic
Paraesophageal Hernia Repair. B.K. Oelschlager, et al. Ann
Surg 2006;244:481.
99 patients randomized to primary repair, with or
without biologic (SIS) mesh. These are the 6 month
followup data on hernia recurrence. No reoperations.
No. Pts.
% Recurrence
Mesh
4
9%
No mesh
12
24%
The premise that the collagen mesh will permanently increase the strength of
the repair is untested and implausible. The primary operation was not
standardized. The experience of the surgeons was not stated. How many
surgeons was not stated. Relationship of recurrence to surgeon was not given.
What was actually done (the various techniques; Nissen or no; etc) was not
reported. The operations were not videorecorded.
Elements of the Operation




Detach the sac from the
stomach
circumferentially.
Excise any sack remnants
attached to the stomach
or GEJ.
Mobilize the lower
esophagus.
Close the hiatus with or
without mesh. Use the
capstan jamming knot to
make it easy.



Nissen fundoplication.
Posterior gastropexy and
collar anchoring stitches
for the plication.
No anterior gastropexy or
gastrostomy in primary
repairs.
Sack Attack
Patient #2: 63 y.o. man
Large HH known for 30 y. Now has dyspnea, heartburn, and chronic abd pain.
The dyspnea is getting worse. Radiographs show that the stomach is in the
chest adjacent to the ribs in the right mid-axillary line, and the transverse colon
is in the chest adjacent to the ribs in the left mid-axillary line.
Abdominal viscera
in the chest
In addition to the
stomach &
transverse colon,
the pancreas was
also in the chest.
Patient #3: 72 y.o. man
Two previous mesh repairs for a
paraesophageal hiatal hernia, 8/06 and
3/07. Now has abdominal pain and
inability to swallow. UGI series shows
recurrent paraesophageal hiatal hernia.
Anterior Nissen Gastropexy
For Paraesophageal HH
The axis of one line of
sutures keeps the
gastroesophageal junction
in the abdomen. The axis
of the second line
prevents the greater
curvature from rotating on
the first line or the GE
junction, thereby
offsetting any tendency of
the fundus to return to the
chest.
The sutures attach the anterior
surface of the stomach to the
diaphragm and posterior rectus
sheath.
This is it, if you really
need to use a gastropexy
for this condition.
Gastropexy
Most pexy operations for abdominal
viscera fail in the long run. Don’t trust
intuition. Results contradict.
 Gastropexy, cecopexy, sigmoidopexy, and
nephropexy return to their original
unwanted orientations. Adding a
gastrostomy doesn’t secure a gastropexy:
the stomach still pulls away.

Posterior gastropexy is the only
pexy that predictably works.
Gastropexy
Thus, anterior gastropexy was largely
abandoned as a primary operation for
paraesophageal hernias by 1990.
 The principal remaining use is as an
emergency measure in bad risk patients.
 Follow Nissen’s method, however. One or
two stitches plus a gastrostomy is not
enough.

Conclusions







There is no difference between Type II & Type
III hernias. There is a continuous spectrum.
Surgery is indicated only for symptoms.
The sac must be completely separated from the
stomach and trimmed, but not “entirely
excised.”
Fundoplication routine.
A 360° wrap cures the reflux in most patients.
Mesh may or may not be used, but is not
important in most cases.
Anterior gastropexy must be done right.