TY  - JOUR
T1  - IMportance of dissection of the hernial sac in laparoscopic surgery for large hiatal hernias
AU  - Watson DI, Davies N, Devitt PG, Jamieson GG
Y1  - 1999/10/01
N1  - 10.1001/archsurg.134.10.1069
JO  - Archives of Surgery
SP  - 1069
EP  - 1073
VL  - 134
IS  - 10
N2  - Hypothesis 
    Laparoscopic repair of large hiatal hernia is an appropriate management strategy.Design 
    A prospective patient series.Setting 
    A university teaching hospital.Patients 
    All patients with hiatal hernias 10 cm or greater in diameter repaired laparoscopically between February 1, 1992, and September 30, 1998.Interventions 
    Two operative strategies were used for laparoscopic repair: the first, which was used until early 1996, entailed initial esophageal dissection while leaving the sac in the mediastinum. The second involved preliminary dissection of the hernial sac from the mediastinum before dissecting the esophagus.Main Outcome Measures 
    Successful completion of the procedure using a laparoscopic technique, postoperative complication rate, reoperation rate, and clinical outcome.Results 
    Eighty-six patients with a large hiatal hernia underwent attempted repair using laparoscopic methods. The median age was 63 years (range, 30-91 years), and 45 patients (52%) were women. There were 30 sliding, 10 rolling, and 46 mixed hiatal hernias. Operating times ranged from 48 to 240 minutes (median, 90 minutes), and 20 procedures (23%) were converted to an open operation. Conversion was significantly more common in the first half of our experience (16 [40%] of 40 patients vs 4 [9%] of 46 patients) before the operative strategy was changed. Esophageal-lengthening procedures were not carried out for any patient. At follow-up of a median of 2 years, 1 patient has moderate dysphagia, 4 patients have reflux symptoms, and 1 patient has undergone further surgery for a recurrent paraesophageal hernia. An overall satisfactory outcome was achieved in 81 patients (94%).Conclusions 
    Large hiatal hernias can be treated effectively laparoscopically. Dissecting the sac fully from the mediastinum before dissecting the esophagus helps to safely mobilize the esophagus, and we think changing to this strategy is the main reason for the improved laparoscopic success rate reported in the latter half of this series.
SN  - 0004-0010
M3  - doi: 10.1001/archsurg.134.10.1069
UR  - http://dx.doi.org/10.1001/archsurg.134.10.1069
ER  -