Laparoscopic antireflux procedures with hepatic shoulder technique for the surgical management of large paraesophageal hernias and gastroesophageal reflux disease.

BACKGROUND

Large paraesophageal hernias are notoriously difficult to manage via laparoscopy and are associated with a significant recurrence rate. A novel laparoscopic approach was used to close the diaphragmatic defect in four patients diagnosed with large, paraesophageal hernias and gastroesophageal reflux disease symptomatology.

METHODS

All procedures were performed via laparoscopy. Three patients underwent a reduction of the paraesophageal hernia with a Nissen fundoplication and one with Collis-Nissen fundoplication. Standard crural closure was performed over a #60 Fr Bougie in two patients, and two patients did not undergo a cruroplasty. In all four patients, the left hepatic lobe was freed, repositioned, and anchored under and inferior to the gastroesophageal junction, propping the gastroesophageal junction anteriorly. This maneuver entirely covers and closes the diaphragmatic defect.

RESULTS

Postoperatively, all patients did well without notable, unusual complaints. Average length of stay was 2 days. Although not statistically significant, all patients had no recurrence of symptoms or of their paraesophageal hernia at 8, 9, 11, and 15 months after the procedure.

CONCLUSIONS

In selected patients, large paraesophageal hernias can safely be managed via a laparoscopic antireflux procedure with the hepatic shoulder technique. Although no long-term follow-up is available, this technique has shown good early postoperative results and may be used as an alternative to a laparoscopic Mesh reinforced fundoplication or difficult crural closure.