Restoration of normal anatomy without fundoplication in non-elective incarcerated giant paraesophageal hernia repair.

BACKGROUND

The purpose of our study was to examine outcomes following a novel approach to management of incarcerated giant paraesophageal hernia in a non-elective setting. Surgical dogma has dictated performing a fundoplication, but we have hypothesized that this is unnecessary in patients without significant reflux presenting with predominantly obstructive symptoms.

METHODS

Patients who presented to the emergency room between January 2010 and June 2024 with symptomatic giant incarcerated paraesophageal hernia with operative repair performed during the same hospitalization were included. An absence of pre-operative reflux symptoms was required. Operative steps included hernia sac reduction, mediastinal mobilization with vagal and crural lining preservation and primary crural closure. An Angle of His reconstruction was performed, and the fundus was sutured to the left hemidiaphragm immediately anterior to the spleen. Objective follow-up was obtained via esophagram, endoscopy, and CT scan.

RESULTS

There were 255 patients with a median age of 81 years. All operations were performed with minimally invasive techniques. The median post-operative length of stay was 6 days. The 30-day mortality was 3.5%, mostly related to complications of pneumonia. Objective follow-up was available in 230 patients at a median of 13 months. There were 13 hiatal hernia recurrences (5.7%): 7 medium (3-4 cm), and 6 large. There were 7 patients that had any heartburn at last follow-up and all were well controlled with medication. Reoperation was performed in 2 patients due to recurrent obstructive symptoms following vomiting episodes. No patient required reoperation for severe reflux.

CONCLUSION

Meticulous hiatal hernia repair with crural closure and restoration of normal anatomy is a safe and effective option in patients presenting in non-elective settings without a significant reflux history. Given increased morbidity with urgent operations, elective repair of giant paraesophageal hernia should be considered in all patients.