Gantert W A, Patti M G, Arcerito M, Feo C, Stewart L, DePinto M, Bhoyrul S, Rangel S, Tyrrell D, Fujino Y, Mulvihill S J, Way L W
Department of Surgery, University of California, San Francisco, 94143-0475, USA.
J Am Coll Surg. 1998 Apr;186(4):428-32; discussion 432-3. doi: 10.1016/s1072-7515(98)00061-1.
Regardless of symptoms, paraesophageal hiatal hernias should be repaired in order to prevent complications. This study reports the University of California San Francisco experience with laparoscopic repair of paraesophageal hiatal hernias, emphasizing the technical steps essential for good results.
From May 1993 to September 1997, 55 patients, 27 women and 28 men, with a mean age of 67 years (range, 35-102 years) underwent laparoscopic repair of paraesophageal hernias at the University of California San Francisco. Symptoms, which had been present an average of 85 months before surgery, consisted mainly of pain (55%), heartburn (52%), dysphagia (45%), and regurgitation (41%). Of the four patients who presented with acute illness, two had gastric obstruction, one had severe dyspnea, and one had gastric bleeding. Endoscopy demonstrated esophagitis in 25 (69%) of 36 patients, and 24-hour pH-monitoring demonstrated acid reflux in 22 (67%) of 33 patients. Manometry detected severely impaired distal esophageal peristalsis in 17 (52%) of 33 patients. The preferred operation consisted of reduction of the hernia, excision of the sack and the gastric fat pad, closure of the enlarged hiatus without mesh, and construction of a fundoplication anchored by sutures within the abdomen.
Of the 55 patients, the operations of 49 were completed laparoscopically using the following reconstructions: Guarner (270-degree) fundoplication (30 patients); Nissen fundoplication (10 patients); and gastropexy (9 patients). Five (9%) operations were converted to laparotomies. The average operating time was 219 minutes; the average blood loss was less than 25 mL; resumption of an unrestricted diet, 27 hours; and mean hospital stay, 58 hours. Intraoperative technical complications occurred in five (9%) patients. One patient died during surgery from a sudden pulmonary embolus. Two (4%) patients required a second operation for recurrent paraesophageal hernias.
Laparoscopic repair of paraesophageal hiatal hernias is safe and effective, but the operation is difficult and good results hinge on details of the operative technique and the surgeon's experience. In this series, the crus could always be closed securely without using mesh. We realized early that a fundoplication should be a routine step, because it corrects reflux and is the best method to secure the gastroesophageal junction in the abdomen.
无论有无症状，食管旁裂孔疝均应修复以预防并发症。本研究报告了加利福尼亚大学旧金山分校腹腔镜修复食管旁裂孔疝的经验，强调了取得良好效果所必需的技术步骤。
1993年5月至1997年9月，55例患者（27例女性，28例男性）在加利福尼亚大学旧金山分校接受了食管旁疝的腹腔镜修复术。术前症状平均出现85个月，主要包括疼痛（55%）、烧心（52%）、吞咽困难（45%）和反流（41%）。4例急性发病患者中，2例有胃梗阻，1例有严重呼吸困难，1例有胃出血。36例患者中25例（69%）内镜检查显示有食管炎，33例患者中22例（67%）24小时pH监测显示有酸反流。33例患者中17例（52%）测压发现食管远端蠕动严重受损。首选手术包括疝还纳、囊袋及胃脂肪垫切除、不使用补片关闭扩大的裂孔以及在腹腔内用缝线固定构建胃底折叠术。
55例患者中，49例手术通过腹腔镜完成，采用以下重建方式：瓜尔纳（270度）胃底折叠术（30例）；nissen胃底折叠术（10例）；胃固定术（9例）。5例（9%）手术转为开腹手术。平均手术时间为219分钟；平均失血量少于25毫升；恢复正常饮食时间为27小时；平均住院时间为58小时。5例（9%）患者发生术中技术并发症。1例患者术中因突发肺栓塞死亡。2例（4%）患者因复发性食管旁疝需要再次手术。
腹腔镜修复食管旁裂孔疝安全有效，但手术难度较大，良好的效果取决于手术技术细节和术者经验。在本系列中，不使用补片总能牢固关闭脚。我们很早就意识到胃底折叠术应作为常规步骤，因为它可纠正反流，且是将胃食管交界处固定于腹腔内的最佳方法。
