Removal of the sac during surgery for the repair of "giant" paraesophageal hernias

Abstract

Background: The presence of a large paraesophageal hernia is a source of concern in foregut surgery. Thus, scholars have focused on ascertaining the optimal surgical approach, methods for reinforcing the esophageal hiatus, and strategies for preventing hernia recurrence and gastroesophageal reflux.

Aim: To investigate the outcomes of surgery for giant paraesophageal hernias without sac removal.

Methods: Sixty-six consecutive patients who underwent surgery for a giant paraesophageal hernia between May 2010 and December 2024 were included in this retrospective study. The pre- and postoperative examinations included upper gastrointestinal endoscopy, X-ray with barium contrast swallow, contrast-enhanced computed tomography (CT) scans of the chest and abdomen, 24-hour potential hydrogen esophageal monitoring, and esophagomanometry. The study group included 36 patients who underwent surgery without sac removal, and the control group included 30 patients who underwent surgery with sac removal.

Results: Fifty-two patients (28 in the study group and 24 in the control group) underwent laparoscopic procedures, 10 (6 in the study group and 4 in the control group) underwent open procedures, and 4 (2 in each group) underwent conversion procedures. The operative time and postoperative length of stay were significantly longer in the control group than in the study group. In 12 patients in the study group, X-ray examination on postoperative days 3-5 revealed air-fluid levels at the site of the remaining hernia sac; all air-fluid levels disappeared without intervention 2 months later. Postoperative day 60 CT and X-ray examinations revealed no pathological changes related to the hernia sac in the mediastinum.

Conclusion: Removal of the hernia sac during surgery for giant paraesophageal hernias is not mandatory. Further large-scale multicentric randomized trials are needed for a more detailed investigation in this field.

Keywords: Hernia repair; Hernia sac; Hiatal hernia; Laparoscopic fundoplication; Paraesophageal hernia.

Figure 1

Surgical approach results. A-D: Mobilization and complete evacuation of the hernia contents into the abdominal cavity (A: Type IV hiatal hernia; The esophageal hiatus is filled with great omentum and abdominal organs; B: Reduction of the transverse colon; C: Reduction of the stomach; D: Mobilization of the tissues inside the hernia sac in the mediastinum. The arrow shows the tissue of the left lung covered with the hernia sac); E-G: Mobilization of the neck of the hernia sac at the level of the diaphragmatic crura (E: A section of the neck of the hernia sac; F: Mobilization is performed, and the grasper fixes the edge of the hernia sac; G: The hernia sac is left in the mediastinum, and the neck of the sac is mobilized at the level of the diaphragmatic crura; H and I: Mobilization of the hernia sac); H: The hernia sac is mobilized and pulled down between the right crura and the esophagus; I: The hernia sac is mobilized and pulled down between the left crura and the esophagus; J-L: Reinforcement of the esophageal hiatus and fundoplication (J: Posterior crurorrhaphy was performed with nonabsorbable sutures; K: Polypropylene mesh was fixed around the esophagus; L: Nissen fundoplication was performed).

Figure 2

Preoperative and postoperative radiologic images. A-D: A patient (29-year-old male) in the study group (A: Preoperative computed tomography (CT) scan showing complete displacement of the stomach into the mediastinum and its rotation; B: Preoperative contrast X-ray of the same patient; C: Postoperative contrast X-ray of the patient on the fourth postoperative day after the open procedure. The orange arrow shows the air-fluid level in the mediastinum; D: Postoperative contrast X-ray image of the patient on the 60^th postoperative day after the open procedure. There was no air-fluid level left in the mediastinum); E-H: A patient (64-year-old female) in the study group (E: Preoperative CT scan showing complete displacement of the stomach into the mediastinum and its rotation; F: Postoperative contrast X-ray of the patient on the fourth postoperative day after the laparoscopic procedure. The orange arrow shows the air-fluid level in the mediastinum; G: Postoperative contrast X-ray image of the patient on the 25^th day after the laparoscopic procedure. The orange arrow shows the air-fluid level in the mediastinum; H: Postoperative CT scan of the patient at 12 months after the laparoscopic procedure. There was no pathologic content left in the mediastinum); I-L: A patient (68-year-old female) in the control group (I: Postoperative X-ray of the patient on the fifth day after laparoscopic hernia repair with removal of the hernia sac; J: Preoperative CT scan showing complete displacement of the stomach into the mediastinum; K: Postoperative CT scan of the patient on the fifth day after laparoscopic hernia repair with removal of the hernia sac. The orange arrow shows the effusion in the mediastinum; L: Postoperative CT scan of the patient on the fifth day after laparoscopic hernia repair with removal of the hernia sac. The orange arrows show the effusion in the pleural cavities). There was no air-fluid level in the mediastinum.