Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1367_Библиотеки_им_академика_М_И_Перельмана
.pdf
46 Khitin and Brams
Chapter 5 / Hiatal Hernia Repair 47
5
Hiatal Hernia Repair
Lev Khitin, MD and David M. Brams, MD
CONTENTS
INTRODUCTIOIN
INDICATIONS FOR PROCEDURE
CONTRAINDICATIONS
REPAIR OF PARAESOPHAGEAL HERNIA
COMPLICATIONS
RESULTS
ALTERNATIVE PROCEDURES
COST
SUMMARY
REFERENCES
INTRODUCTION
The history of surgery for hiatal hernia and gastroesophageal reflux disease (GERD)
has paralleled our gradual understanding of the physiological features of the esophagus.
The association between GERD and esophagitis was not established until the 1940s, and
much controversy arose concerning the relationship between hiatal hernia and GERD.
Initial attempts at simply reducing the hernia by closing the crura proved to have unacceptably high failure rates. The Allison repair, introduced in 1951, involved mobilization of the distal esophagus with placement of the gastroesophageal junction within the
abdomen and repair of the crura. This operation had a high recurrence rate, and subsequently several attempts were made at both fixing the gastroesophageal junction
within the abdomen and wrapping the gastric fundus around the distal esophagus
(fundoplication) to create an antireflux valve (1).
The most commonly performed hiatal hernia repair is the Nissen fundoplication. This
was first performed in 1937 in a patient with a perforated ulcer of the gastric cardia in an
effort to protect the repair. Because this patient subsequently had no evident reflux,
Nissen performed this operation purposefully in patients with GERD. Other fundoplications that have become eponymic were subsequently developed, applied, and reported;
but modifications of the Nissen fundoplication are currently the most widely used operations for GERD and hiatal hernias, (see Chapter 4, Table 1) (1,2).
From: Clinical Gastroenterology: An Internist's Illustrated Guide to Gastrointestinal Surgery
Edited by: George Y. Wu, Khalid Aziz, and Giles F. Whalen © Humana Press Inc., Totowa, NJ
47
48 Khitin and Brams
Fig. 1. Type II hiatal or pure paraesophageal hernia: coronal section. Gastroesophageal junction
is in normal intrabdominal position.
The term hiatal hernia refers to the protrusion of any structure other than the esophagus through the esophageal hiatus of the diaphragm and generally refers to a sliding
hiatal hernia or a paraesophageal hiatal hernia. The most generally accepted nomenclature of hiatal hernia includes four principal categories. Type I, or sliding hiatal hernia,
accounts for more than 90% of all hiatal hernias (see Chapter 4, Fig. 4). The
esophagogastric junction is displaced through the hiatus into the mediastinum because
of circumferential weakening of the phrenoesophageal membrane. Eighty percent of
patients with GERD have type I hernia. Type II, or paraesophageal hernia, accounts for
less than 5% of hiatal hernias (Figs. 1 and 2). Type II hernia occur more commonly in
an older population than do sliding hiatal hernia. The esophagogastric junction remains
fixed below the diaphragm, and the gastric fundus herniates through the defect into the
mediastinum. Type III is a combination of both types I and II hernia (Fig. 3). Components
of both sliding and paraesophageal hernia are present. It is seen in more than 5% of
patients. Finally, Type IV is comprised of anatomically complex hiatal hernias. In
addition to sliding and paraesophageal components, Type IV hernia contain other viscera such as the colon, omentum, small intestine, pancreas or spleen (Figs. 4 and 5) (2,3).
Other rare hernias may occur in the hiatal region, including parahiatal hernias that can
be differentiated from types I through IV in that there is a separate extra-hiatal diaphragmatic defect in which intervening normal crural muscle tissue is present. They are rarely
seen and may be associated with previous trauma. Additionally, congenital diaphragmatic hernias (Bochdalek—posterolateral or Morgagni—retrosternal) are more likely to
present in childhood but may not be found until much later in life (2–4).
Chapter 5 / Hiatal Hernia Repair 49
Fig. 2. Type II hiatal or pure paraesophageal hernia: upper gastrointestinal contrast study.
INDICATIONS FOR PROCEDURE
The majority of sliding hiatal hernias are asymptomatic. Only when surgical intervention is indicated for GERD should Type I (sliding hiatal hernia) be repaired (see
Chapter 3) (2).
The presence of Type II paraesophageal hiatal hernias has traditionally been considered an indication for surgery in a patient who is otherwise fit for surgery. Paraesophageal
hiatal hernias have been associated with the risk of strangulation of incarcerated viscera
and the potential need for emergency operations. In their classic article from 1967,
Skinner and Belsey found that 6 of 21 patients under review for paraesophageal hernias
developed gastric volvulus and died of the catastrophic complications of strangulation,
perforation, exsanguinating hemorrhage, or acute dilatation of the herniated intrathoracic stomach. Although other series reported similar findings to that of Skinner and
Belsey, more recent large series suggest that symptoms associated with paraesophageal
50 Khitin and Brams
Fig. 3. Type III or mixed sliding and paraesophageal hernias: coronal section.
Fig. 4. Type IV hiatal hernia: combination of type III with herniation of other viscus (colon).
hernia may develop more gradually. Allen et al. followed 23 patients for a median of 78
mo and found only three cases of gastric strangulation in 735 patient years of follow-up (5).
Although the true incidence of gastric volvulus presenting with strangulation is controversial (ranging from 3–30%), the elective repair of paraesophageal hernia is generally recommended because emergency surgery for acute complications carries a high
mortality rate (5,6).
There are two patterns to gastric volvulus, organoaxial and mesenteroaxial (Figs. 6
and 7). Organoaxial volvulus occurs when 180° torsion occurs about the stomach’s
longitudinal axis. Mesenteroaxial volvulus is less common and occurs with torsion about
Chapter 5 / Hiatal Hernia Repair 51
Fig. 5. Type IV hiatal hernia: barium enema study demonstrates herniated colon.
Fig. 6. Paraesophageal hernia: gastric volvulus.
the vertical axis. Thirty percent of patients with paraesophageal hiatal hernia present
with hematemesis or exhibit anemia, which is likely caused by mucosal hemorrhage
52 Khitin and Brams
Fig. 7. Paraesophageal hernia: gastric volvulus. Upper gastrointestinal contrast study.
from venous congestion located at the neck of the hernia. They may also complain of
dysphagia, early satiety, referred diaphragmatic pain with postprandial gastric distention, and weight loss (7).
About 30% of patients with paraesophageal hernia have Type 3 hernia and have
symptoms of GERD. Many patients with paraesophageal hernia have no serious symptoms or complications of their condition for years. As the hernia progresses, varying
degrees of complaints and severity of symptoms will be directly attributable to the
configuration of the hiatal hernia (2).
Gastric volvulus presenting with infarction occurs when the stomach dilates and
gastric ischemia occurs. Progression of ischemia can lead to perforation. Symptoms of
epigastric pain, the inability to vomit, and gastric obstruction on contrast study are
indication for emergency intervention (2).
When patients with paraesophageal hiatal hernias are considered for operative repair,
diagnostic tests should include upper endoscopy to exclude other significant esophageal
mucosal disease, upper gastrointestinal contrast radiographs to classify the type of
hiatal hernia and give an indication of the degree of esophageal shortening, and esophageal manometry to assess the adequacy of esophageal peristalsis (2,6).
Chapter 5 / Hiatal Hernia Repair 53
CONTRAINDICATIONS
There are few absolute contraindications for an operation, including inability to tolerate a general anesthetic or an uncorrectable coagulopathy (2,4,6).
REPAIR OF PARAESOPHAGEAL HERNIA
The repair can be performed transthoracally, transabdominally, or laparoscopically.
Factors including patient age, medical conditions, elective vs emergency procedure,
presence of esophageal shortening, prior surgery, obesity, and body habitus all influence
choice of surgical approach and procedure performed (2,4,6).
The thoracic approach is favored in patients who are obese, who have had extensive
upper abdominal surgery, and who have a type III hernia with severe esophageal shortening necessitating extensive esophageal mobilization or a lengthening procedure.
The majority of cases are best approached transabdominally. Through this approach
the volvulus is readily reduced, gastropexy can be performed, and if esophageal mobilization is not adequate, a lengthening procedure can also be performed.
Laparoscopic repair of paraesophageal hernia has been reported in numerous series.
Although the technique is similar to that of the standard laparoscopic Nissen
fundoplication, the technical difficulty of repair of paraesophageal hiatal hernias is
generally much greater than that for antireflux surgery alone. The inherent difficulties
of this operation include the underlying physical status and frequent comorbidities of the
patient, the often compromised nature of the gastric wall, which has been incarcerated
chronically in a mediastinal hernia sac, the necessity of excising the hernia sac without
damaging critical structures, and the problem of closing the enlarged hiatus adequately.
Therefore, unlike the standard laparoscopic Nissen done for reflux, laparoscopic repair
of paraesophageal type II, III, and IV hernia should only be done in tertiary care centers
by surgeons with extensive experience in laparoscopic antireflux surgery (2,4,6).
The repair of a paraesophageal hernia is performed transabdominally through an
upper midline incision, or laparoscopically with five to seven trocars under general
anesthesia. The critical steps of the procedure are as follows:
1. Mobilization of gastric fundus. The short gastric vessels are divided and the left crus
is identified.
2. Reduction of stomach into peritoneal cavity. Mobilization of the hernia sac from the
mediastinum facilitates reduction of the gastric fundus. The hernia sac is either completely resected or at least circumferentially transected at the hiatus.
3. Identification and mobilization of the esophagus and vagus nerves. The esophagus must
be fully mobilized distally to allow reduction into the peritoneal cavity without tension.
4. Closure of hiatus. The crura are approximated. Nonabsorbable mesh is occasionally
employed to close the defect.
5. Fundoplication. A loose 360° nissen fundoplication is created over a bougie.
6. Gastropexy. The body of the stomach is sutured to the abdominal wall with placement
of gastrostomy tube (1,6,7).
There are several controversies regarding repair of paraesophageal hiatal hernias.
These include the necessity of excising the hernia sac, the best technique for closing the
diaphragm, the requirement of an antireflux procedure, and the need to perform a gastropexy. There are few definitive studies to answer these questions.
54 Khitin and Brams
Most authors recommend routinely performing a fundoplication. First, two-thirds of
patients with paraesophageal hernia have objective evidence of GERD. Second, even
though GERD may not be a complaint before the operation, the extensive periesophageal
dissection performed during this operation may lead to significant postoperative GERD.
Finally, the presence of the fundoplication helps to fix the wrapped fundus in the abdomen, because its diameter is greater than that of the esophagus by itself (1,4,7).
COMPLICATIONS
Morbidity of surgery for paraesophageal hernia repair is significantly greater than that
for antireflux surgery alone. The poorer outcomes are both a result of the nature of the
patient population and the difficulty of the operative approach. Patients with
paraesophageal hiatal hernias are significantly older with more comorbidities than the
usual patient undergoing an antireflux operation. The average age of patients with a
paraesophageal hernia is 70–80 yr. These patients commonly have significant preexisting conditions. Complications, such as atelectasis, pneumonia, deep venous thrombosis,
pulmonary embolism, myocardial infarction, and arrhythmias, may occur (1,8).
Complications are more frequent than those reported with antireflux surgery. Traumatic visceral injury or vagus nerve injury occurred in 10–15%. Pneumothorax occurred
in 5–10% because of the more extensive mediastinal dissection. Subcutaneous emphysema occurred in 50% of laparoscopic cases, but resolved spontaneously as carbon
monoxide is absorbed.
In most series, 10% of patients have dysphagia, poor gastric emptying, recurrent
hernia, and GERD leading to suboptimal outcome after paraesophageal hernia repair.
Recurrence of the paraesophageal hiatal hernia can occur and be asymptomatic. This
may be caused by an inability to close the hiatus in a tension-free fashion. Several authors
have recommended placement of a prosthesis at the hiatus. However, cicatricial involvement of the esophagus by a piece of mesh can lead to significant complications (3,6).
Postoperative complications are encountered 20–30% of patients, and reoperations are
necessary in nearly 10% of patients. Mortality following elective repair is less than 5%, and
in centers with a large volume of esophageal surgery, mortality should be less than 1% (5,8).
RESULTS
Most studies report relief of symptoms in more than 90% of patients with follow-up
for more than 5 yr. These results are true of laparoscopy, laparotomy, and thoracotomy.
Long-term results of open repairs suggest that 83–100% of patients remain symptom free
after a mean follow-up of 6 yr. Laparoscopic repair is as successful and safe as open.
Laparoscopic repair, in expert hands, has a shorter hospital stay, a lower hospital cost,
and increased patient satisfaction. However, the long-term durability of laparoscopic
repairs is as yet unknown. Some retrospective studies suggest that transthoracic approach
for large paraesophageal hernia might be associated with the highest likelihood of a
durable repair (5,8).
ALTERNATIVE PROCEDURES
Patients who are debilitated and are not candidates for formal repair of paraesophageal
hernia may be treated with gastropexy performed with gastrostomy. Although this will
Chapter 5 / Hiatal Hernia Repair 55
not allow complete reduction of the fundus from the hernia sac, gastropexy will eliminate
the risk of volvulus and strangulation. This is rapidly performed either laparoscopically
or through a small laparotomy (5,6).
COST
Cost of repair of paraesophageal hernia varies and depends on the size and complexity
of the hernia. Overall, it can be as low as $5000 for hospital cost and $7000 for total cost
for laparoscopic repair of a type II paraesophageal hernia, followed by an antireflux
procedure. However, cost can be significantly higher for repair of large, long-standing,
complex hernias in old debilitated patients who may have prolonged, complicated hospital courses (9).
SUMMARY
1. Sliding (type I) hiatal hernias are only repaired when associated with significant symptoms of GERD. Laparoscopic Nissen fundoplication is the usual repair performed.
2. Paraesophageal (type II, III, and IV) hernias are relatively uncommon. Most occur as
mixed-type hernias in association with a sliding hiatal hernia.
3. Paraesophageal hernia are present in an elderly population with symptoms of early satiety,
dysphagia, dyspnea, and chest pain.
4. Paraesophageal hernia can present as a gastric volvulus. This can occur with strangulation necessitating emergency surgery with high morbidity and mortality. Good surgical
risk patients should be offered elective hernia repair.
5. The surgical management of patients with paraesophageal hernias can be complicated.
The anatomic derangements are complex and variable.
6. Laparoscopic paraesophageal hernia repairs require advanced skills and a thorough
knowledge of the hiatal area and include hernia reduction, crural closure, fundoplication,
and gastropexy.
REFERENCES
1. Bowrey DJ. Laparoscopic esophageal surgery. Surg Clin N Am 2000;80:1213–1241.
2. Oddsdottir M. Paraesophageal Hernia. Surg Clin N Am 2000;80:1243–1253.
3. Williamson WA, Ellis FHJ, Streitz JMJ, et al. Paraesophageal hiatal hernia: is an anti-reflux procedure
necessary? Ann Thorac Surg 1993;56:447-451.
4. Skinner DB, Belsey RH. Surgical management of esophageal reflux and hiatal hernia. Longterm
results with 1030 patients. J Thorac Cardiovasc Surg 1967;53:33–54.
5. Soper NJ. Laparoscopic management of hiatal hernia and gastroesophageal reflux. Curr Probl Surg
1999;36:765–838.
6. Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal hernia repair. Arch Surg 1997;
132:586–589.
7. Hashemi M, Sillin LF, Peters JH. Current concepts in the management of paraesophageal hiatal hernia.
J Gastroenterol 1999;29:8–13.
8. Trus TL, Bax T, Richardson WS, et al. Complications of laparoscopic paraesophageal hernia repair.
J Gastrointest Surg 1997;1:221–228.
9. Frantzides C. Laparoscopic repair of large hiatal hernia with polytetrafluoroethylene. Surg Endosc
1999;13:906–908.
Соседние файлы в папке Библиотека им академика М.И. Перельмана