Paraesophageal hernias: Indications and surgical treatment

Laparoscopic paraesophageal hiatal hernia repair is a complex operation that requires experience with advanced minimally invasive surgical techniques, as well as an expertise in both the anatomy and physiology of the esophagus and stomach. When performed correctly the operation should result in a high rate of symptomatic resolution with a low complication profile, despite often being performed in patients who are elderly with multiple medical comorbidities. However, if the principles of a proper repair are not followed, patients can be left with persistent dysphagia and/or gastroesophageal reflux, resulting in a worse quality of life than they had preoperatively and possibly necessitating reoperation. This chapter outlines the preoperative assessment, evaluation, and indications for surgery in patients presenting with paraesophageal hernia. The key steps and components of a laparoscopic repair are detailed, with an emphasis on adherence to the fundamentals of creating a functional repair. These include creating a setup and port placement that allows for efficient and effective operating, complete dissection and reduction of the hernia sac, mobilization of the distal esophagus, performing a tension-free crural repair, and creation of an effective antireflux fundoplication. The decisions of when to perform an esophageal lengthening procedure and/or reinforce the crural repair with a mesh are also addressed. While surgeons must tailor their technique to their own operating style and individual patient anatomy, if these basic principles and steps are adhered to, the operation should lead to successful and durable outcomes on a consistent basis.