Laparoscopic anterior gastropexy for type III/IV hiatal hernia in elderly patients

Abstract

Introduction: Large esophageal hiatal hernias occur most commonly in elderly patients with comorbidities, in whom even an elective surgery cannot be performed without high risks. Although fundoplication is recommended for esophageal hiatal hernia repair, we prefer not to limit our options to fundoplication, as obstruction is a frequent main complaint. We favor an anterior gastropexy approach instead to perform anti-reflux surgery and prevent recurrent protrusion and torsion of the incarcerated organ with minimal risk. The aim was to evaluate the safety and effectiveness of anterior gastropexy for large hiatal hernia in elderly patients with comorbidities.

Case presentation: We retrospectively evaluated 8 patients who underwent laparoscopic anterior gastropexy for large hiatal hernia (type III or IV) since 2006. All patients were women with a median age of 82 years (range, 74-87 years). The major complaint was obstruction in all patients, with relatively mild reflux symptoms. They underwent successful laparoscopic surgery with no conversion to laparotomy. Fundoplication was performed in 4 cases. No perioperative complications occurred, and the main complaint resumed rapidly in all patients, without recurrence during postoperative follow-up of median 48 months (range, 5-77 months).

Conclusion: Laparoscopic anterior gastropexy is safe and effective and can be considered as one of the practical surgical options for large hiatal hernias in elderly patients, whom surgical intervention should be minimized due to their comorbidities.

Keywords: Anterior gastropexy; Elderly patients; Large esophageal hiatal hernia.

Fig. 1

The type III/IV hiatal hernia before and after surgery. Upper gastrointestinal series is a large hiatus hernia (type III or IV) patient at preoperative (a) and postoperative (b)

Fig. 2

Hiatus repair. The hiatus (a) on the dorsal side of the esophagus was closed (b), and additional mesh reinforcement was provided (c)

Fig. 3

Anterior gastropexy. Suturing the anterior stomach wall to the anterior abdominal wall at 2 sites using 2-0 Prolene (a, b, d) fixing the gastric wall on the anterior layer of the rectus sheath (subcutaneous) (c, d)

Fig. 4

Twenty-four-hour pH monitoring. The fraction time of pH <4 (%) improved (n = 4) or maintained normal (n = 1) in all 5 patients (a). The DeMeester score improved (n = 3) or maintained normal (n = 1) (b). The remaining 1 patient showed deterioration of DeMeester score (preoperative score 8.8 vs. postoperative score 29.7)