Laparoscopic Articles from Laparoscopy Hospital

DR. SAJAL KUMAR
MS .DMAS

ABSTRACT

Giant hiatal hernia is defined as greater then one third of the stomach in the thoracic Cavity (1) and representing 5 to 10 % of all hiatal hernia (8). The hiatal opening in a patient with a large hernia is wide, with the right and left Crura very thin and often separated by 5 cm or more (8). The aim of this review is to analyze the role of laparoscopy in the management of Giant hiatal hernia.

INTRODUCTION

Traditionally repair of giant paraesophageal hernia has been performed through and Open laparotomy or thoracotomy, with the advent of laparoscopy, nowadays giant Hiatal hernia are performed with laparoscopy

Saveral recent report have shown that laparoscopic repair of paraesophageal hiatal hernia

Is feasibadle and effective obtaining comparative result to open surgery (2)

MATERIAL AND METHOD

A review of article was done through the internate using search engine Google, high wire press springerlink pubmed through the internate facility available
In laparoscopy hospital in Delhi.–using

About 3500 article available on the net only selected article weve selected article were screened for further reference. Operative procedure selected only from the centre, where the study was done, are specialized in laparoscopic surgery.

KEYWORD

Giant hiatal hernia, Laparoscopy management, complication, recurrence.

SURGICAL PROCEDURE

Pre-operation workup including carefule history regarding patient symptom

• Barium swallow x-ray
• Upper gastrointestinal endoscopy
• Esophageal manometry
• Ph monitoring

Should be done

AIM AND OBJECTIVE

The aim of the study was to evaluate the effectiveness and safety to laparoscopy in the Treatment of hiatal hernia.

•  Operative time
•  Operative Technique
•  Post operative pain
•  Complication
•  Hospital stay
•  Functional index
•  Quality of life analysis

The following parameter were eveluated

OPERATIVE PROCEDURE

The surgical technique employed include

•  Standerd five cannula technique
•  Devide the lesser omantom to expose the right hilar piller with in the sac
•  reduction of hernia by means of atraumatic grasper in a hand over hand fashion
•  complete excision of sac
•  primary closure of hiatal hernia defect with either suture approximation of crura or by defferent type of mesh application (for tension free repair)
•  after closing the hiatus a fundoplication (Nissen or toupet) with or without collis gastroplasty will complete the operation depending upon the finding of intraoperative assessment of short esophagus and esophageal manometry.

Review of citation

M. Morino et all 2006. Performed laparoscopic repair of giant hiatal hernia on 65 patients Oct 1991- April 2003.

•  Primary closure of the hiatal defect was done in 14 cases
•  Tension free repair using a mesh was performed in 37 cases
•  14 patients underwent collies – Nissen gastroplasty.
•  There was no intra operative complication and no conversion to open technique
•  Mesh operation time was 130 min
•  No motility
•  One major complication (1.5%)
•  An esophageal perforation
•  Post operative complication – 12 patients has transient sub coetaneous emphysema in the neck, resolve spontaneously
•  Mean hospital stay was 4.8 day
•  Transient dysphagia occurred in 7 patients
•  Recurrent hernia present in 23 patients (35.4%)
•  Recurrent rate was 77% in direct suture and 35% when mesh was used.

Recurrence of hiatal hernia according to type of surgical technique are:

Table No: 1 – Result of Recurrences

PTFE, Polytetrafluoroethylene
Source: M. Morino et al

No patients with a collies- Nissen fundoplication experience recurrence.

R. parmeswaram et al 2006 performed laparoscopic repair of large paraesophageal hiatal hernia between Jan 2000 and July 2004 on 49 patients (12) .

•  The median age of these patients was 68 years
•  The techniques used Nissen fundoplication
•  There were two conversion to open surgery
•  Major morbidity was atrial fibrillation, pulmonary embolism and splenectomy rate was 10.2%.
•  Minor morbidity included – chest infection, jaundice, dysphagia, small pnumothorex rate was 20.4%
•  Recurrence rate of 27 patients that is 66% patients.

L. E Ferri et al 2005. Performed repair 60 cases paraesophageal hernia for reevaluation of result of laparoscopic repair against open laparotomy from 1990 to 2002 (13) .

•  For this study 25 cases repaired with open trans abdominal
•  35 cases laparoscopic repair
•  Laparoscopic repair resulted in
•  Lower blood loss
•  Fewer intraoperative complication
•  Shorter length of hospital stay
•  Radiological recurrence was 44% for open and 23% for laparoscopic procedure
•  Laparoscopic repair was associated with a significant reduction in time to oral intake, parental opoid use and length of hospital stay

Table 2 : operative and short tern outcome after open and laparoscopic paraesophageal hernia repair:

a Complication classification as proposed by Clavien et al.{14}

Source: L.E. Ferri et al (13)

Antomic recurrence was identified in 8 of 18 open and 7 of 31 that is (23%) patients in the laparoscopic group five recurrences occurred in the first 15 patients where only 2 of the last 20 patients have had recurrence.

James D Luketich M.D. et al : In October 2000 performed laparoscopic surgery for giant hiatal hernia from July 1995 to February 2000 on 100 patients.

•  There were three cases in which open conversion done due to adhesion
•  Then median surgical time was 3.6 hours
•  Median length of stay was 2 days.
•  The crural repair was primary in 96 patients and 4 had mesh repair
•  72 patients got Nissen fundoplication and 27 collies-nissen fundoplication
•  Intraoperative complication include
•  Pneumothorex 4 patients
•  Esophageal perforation 5 patients
•  Gastric perforation 3 patients
•  Major Perioperative complication include stroke 1 patients, MI-1 patients, ARDS-1 patients, Pulmonary emboli-3 patients, reoperation for abscess 2 patients, recurrent hernia 1 patients.
•  Overall surgical death rate 1 percent (5) .

Andrew F. Pierr. M.D et al (2002) performed elective repair of giant paraesophageal hernia in 2003 patients between June 1995 to July 2001.

•  Mean age was 67 year
•  Laparoscopic procedure included
•  69 patients Nissen fundoplication
•  112 collies-nissen fundoplication
•  19 other procedure
•  Three open correction due to adhesion
•  Median length of hospital stay was 3 day
•  Minor and major complication in 57, (28%) patients
•  Postoperative esophageal leak 3%
•  Death 1%
•  Recurrence hiatal hernia 5 patients
•  Result
•  Excellent in 128 patients
•  Good result in 12 patients
•  Fare result in 7 patients
•  Poor result in 5 patients
•  Based on post operative follow up and GERD questionnaire (1) .

Discussion

There are now several study report, the outcome of laparoscopic management of giant of hiatal hernia (5, 10, 11, 12, 13, 14) . Probably the first successful repair was described by Sir Alfred Cushieri and coworker in 1991. Since than laparoscopic technique have been used increasingly in the approach to patients with paraesophageal hernia (11) .

Rate of recurrence after laparoscopic repair have been variable. Some studies have reported a high recurrence rate of 42% in other study have reported lower recurrence rate. Than anatomic recurrence rate in the series of R. parmeswaram et al 2006 was 17.85%, which is consistent with other series.

Table 3. Review of various study with radiological follow up data

Source: R. Parmeswan et al.

Various methods have been used to reduce the rate of recurrence. Those are:

•  Prosthetic mesh insertion
•  Use of Teflon pledgetted horizontal mattress suture to encircle fiber bundle of both crus of diaphragm.
•  In case of short esophagus found on intraoperative endoscopy
•  Add an esophageal lengthing of procdure during the crural repair ie collies-nissen gastroplasty to achieve a tension free intra abdominal repair etc. the rate of recurrence is higher in the learning curve after which the failure rate diminished (13) .

Although laparoscopic repair of giant hiatal hernia is a techniqually challenging procure but, with the gain of experience result is compare favorably to the open operation (10, 11, 1,8) .

Laparoscopic approach to paraesophageal hiatal hernia offer an excellent visualization of the hiatal region during the phase of hernia reduction the laparoscopic approach allow very precise identification of the anatomic structure and dissection is facilitated by pheunoperitonium.

Laparoscopic repair of large hiatal hernia is now safe and effective technique for the management because patient population often consisting of elderly, debilitating patient, avoiding an open procedure, may prove beneficial. This is techniqually challenging procedure but as experienced gained and committed follow up is performed. We belief this approach well provide an excellent option for patient with paraesophageal hiatal hernia (10) .

Conclusion

Although techniqually demanding this approached provide better exposure of the surgical field than open transadominal procedure and add the known general advantage of laparoscopy in term of reduced morbidity, shorter hospital stay rapid and recurpation, and decreased pain medication. This advantage may be especially valuable in the paraesophageal hernia patient population because most patients are elderly and have multiple comorbid condition.

Acknowledge

I specially thank Prof Dr. R. K. Mishra for his guidance for completion of this review article.

Reference

1. Andrew F. Pierre, et al Aug-2007. Result of laparoscopic repair of giant paraesophageal hernia: 2000 consecutive patient.
2. Giovanni Ganinotto. Objectives follow up after laparoscopic repair of large type III hiatal hernia assessment of safety and durability .
3. Bas P.L Wijnhoven et al jan 2008 laparoscopic repair of a giant hiatal hernia. How I do it.
4. Eduardo M. Targarona MD, phd et al dec.2004 mesh in the hiatus a controversial issue
5. James D Luketich et al Oct (2000) laparoscopic repair of giant paraesophageal hernia: 100 consecutive case.
6. L. Fei, G. del genio et al. April 2006- crura ultrastructral alternation in patient with hiatal hernia: Pilot study
7. Frantzides CT et al: a prospective, randomized trail of laparoscopic poly tetrafluroethylene patch repair vs. simple cruroplasty for large hiatal hernia.
8. M. Morino et al. 2006 laparoscopic management of giant hiatal hernia factors influencing outcome
9. Bryan A et al July 2006. Wedge gastroplasty and reinforced crural repair: Important component of laparoscopic giant or recurrent hiatal hernia repair.
10. Wiech mann R.J et al- laparoscopic management of giant paraesophageal hernitation- Ann of thoracic surgery 2000
11. Surgio Diaz MD et al may 2002 laparoscopic paraesophageal hernia repair a changing operation: medium term outcome of 116 patients.
12. R. Paramswaran et al 2006- laparoscopic repair of large paraesophageal hiatal hernia: quality of life and durability.
13. L. E. Ferri et al 2005- should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach.
14. Clavien L A et al-proposed classification of complication of surgery with example of utility in cholecystectomy.
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17. Hashemi M, et al (2000) Laparoscopic repair of large type III data hernia: objective follow-up reveals high recurrence rate.
18. Martin TR, et al (1997) management of giant paraesophageal hernia.
19. Trus TL, et al (1997), complications of laparoscopic paraesophageal hernia repair.
20. Wu JS, Dunnegan Dl, et al (1999).