A technique for the laparoscopic repair of paraoesophageal hernia without mesh

Abstract

Laparoscopic paraoesophageal hernia repair is a challenging procedure, both in surgical technical difficulty and in prevention of recurrence, in the setting of operating on an older patient cohort with associated co-morbidities. However, modifications based on sound surgical principles can lead to better outcomes. This article describes and illustrates in detail the technique for the laparoscopic repair of paraoesophageal hernia without mesh with cardio-oesophageal junction fixation. The data and results of the study supporting this technique have been published previously by Gibson et al. (Surgical Endoscopy 27: 618-623, 2013). The previously published article has reported on the numbers of patients, mean age, American Society of Anesthesiologists Physical Status Classification System, body mass index, duration of follow-up, complications, Visick scores and quality of life pre- and post-operatively. The principles of complete reduction of the hernia sac, preservation of both crura, mobilisation of the phreno-oesophageal ligament and phreno-gastric attachments, adequate mediastinal mobilisation of the oesophagus and the cardio-oesophageal junction into the abdomen without tension, preservation of both vagi, a tension-free crural repair including the fascial aspects adjacent to the diaphragm, an anterior hiatal repair in combination with the recognised posterior approximation, a loose fundoplication and a secure cardiopexy to the median arcuate ligament and multiple points of attachment; we have found leads to good operative results(Gibson et. al.) without the need for mesh. This article outlines in detail the operative technique guided by these principles with annotated intra-operative photographs illustrating the anatomy and procedure. The technique used by our team since March 2009 for the last 154 cases, based on the experience of an aggregate of 544 cases since 1999, we believe results in an acceptable level of symptomatic and anatomic recurrence without using mesh.