Management of acute paraesophageal hernia

Acute paraesophageal hernia is a surgical emergency presenting with sudden chest or abdominal pain, dysphagia, vomiting, retching or significant anemia. Severe cases can present with respiratory failure or systemic sepsis. This can be due to gastric volvulus, incarceration, strangulation, severe bleeding or perforation. Traditionally this has been treated with an open surgery. The purpose of this study is to develop a management algorithm and evaluate the role of a laparoscopic approach for these cases. A retrospective chart review was performed for patients operated on for paraesophageal hernia at the Peter Lougheed Centre from 2004 to 2007 inclusive. Patients admitted with acute symptoms requiring emergency surgery were selected for the study. Twenty patients were identified. Seventeen patients underwent successful laparoscopic repair including reduction of the hernia content, excision of the sac, crural closure, and fundoplication (Dor or Nissen). Fifteen of these were done semi-urgently. Three patients had open repair. One patient was converted to open due to ischemic gastric perforation and peritoneal contamination. Another patient had right thoracotomy followed by laparotomy for mediastinal contamination. A third patient with a body mass index (BMI) of 49 kg/m(2) was converted to open for a type VI paraesophageal hernia. Mean operating time for the laparoscopic group was 190.5 min, blood loss was minimal, and mean postoperative hospital stay was 8.2 days. There were no significant perioperative complications. All patients were tolerating regular diet on short-term follow-up. Laparoscopic repair of acute paraesophageal hernia is safe and feasible with low morbidity and mortality. It affords all the benefits of minimally invasive surgery in a group of patients that are often elderly and suffer from multiple medical problems. Based on our experience, we advocate the laparoscopic technique to repair acute paraesophageal hernias in patients with no obvious perforation. A management algorithm is also suggested.