Operative strategy of a paraesophageal hernia repair

What is the operative strategy of a paraesophageal hernia repair? 

The key steps of paraesophageal hernia repair are:

  • Return stomach and esophagus to their normal intraabdominal positions.
  • Remove the hernia sac.
  • Close the hiatus.
  • Anchor the stomach below the diaphragm.

In most circumstances, a fundoplication is added both to augment the LES and to aid in stabilizing the repair below the diaphragm. Many recent studies also advocate the use of a mesh to reduce the recurrence rate.

There are three approaches for the surgical repair of paraesophageal hernias: transabdominal, transthoracic, and laparoscopic.

Traditionally, a transthoracic repair has been advocated because of the relative ease of mobilizing the esophagus and dissecting out the hernia sac and its contents. However, as the stomach is reduced blindly into the abdomen, an organoaxial rotation of the stomach could persist or redevelop and lead to an intraabdominal gastric volvulus.

The abdominal approach is now preferred with the main advantage being the ability to place the stomach into the appropriate anatomic orientation.

Laparoscopic repair offers the advantages of decreased length of postoperative discomfort, earlier return to regular activities, and shorter hospital stay.

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