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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
GIANT PARAESOPHAGEAL HERNIAJ Leroy, MD, F Jamali, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France 1. Description Unlike sliding hiatal hernias, para-esophageal hernias (PEH) present significant risks of catastrophic complications (upper gastro-intestinal hemorrhage, gastric volvulus, gastric necrosis and perforation, etc.) and should be repaired. This case illustrates one such giant para-esophageal hernia and its management. 2. KeywordsPara-esophageal hernia, giant hiatal hernia, GERD, antireflux procedures 3. PatientFemale, 64-year-old 4. Medical history- hypertension; - history of gout/hyperuricemia; - clinical depression; - heavy smoking; - left inguinal hernia repair 10 years ago. 5. History of present illnessThe patient presents with a long standing history of severe heartburn. Recently, the symptoms have worsened with new onset epigastric pain, frequent regurgitations and recurrent episodes of vomiting. The patient denies loss of appetite, weight loss or systemic constitutional symptoms. Because of the retrosternal chest pains, a cardiac workup is undertaken and shows no abnormalities. 6. Chest X-rayA chest X-ray taken during this workup reveals a large gas bubble intrathoracically at the level of the hiatus. 7. Physical examinationThe patient is moderately obese. Chest auscultation reveals high pitched bowel sounds. Abdominal examination shows no specific abnormalities. The rest of the exam is otherwise negative. 8. Laboratory values- screening laboratory workup is negative; - Hgb = 14 g/dL (N 13.5-18) 9. Upper endoscopyIntestinal metaplasia starting at 36 cm from the incisors with no ulceration. Large para-esophageal hernia with external compression on the esophagus. Because of herniation of the pylorus into this para-esophageal hernia, the duodenum could not be explored. 10. Contrast swallowLarge para-esophageal hernia involving the distal stomach. The cardia and gastroesophageal junction are in their normal anatomical position. 11. MRILarge para-esophageal hernia with compression of the distal esophagus demonstrated on gadolinium swallow. 12. ProcedureThe patient undergoes a laparoscopic para-esophageal hernia repair with mesh reinforcement of the primary crural closure and a Nissen-Rossetti antireflux procedure.  Video 12 13. Follow-upThe patient has an uneventful postoperative course and is discharged on postoperative day 4. On follow-up, he notes disappearance of reflux symptoms. 14. DiscussionUnlike sliding hiatal hernias, para-esophageal hernias (PEH) present significant risks of catastrophic complications (upper gastro-intestinal hemorrhage, gastric volvulus, gastric necrosis and perforation, etc.) and should be repaired. PEH appear to be associated with increasing age as the mean age of patients in most series exceeds 65 years (Wu et al. , 1999; Frantzides et al. , 1999; Edye et al. , 1998; Hashemi et al. , 2000; Watson et al. , 1999). A significant experience has been accumulated in the literature demonstrating the safety and feasibility of the laparoscopic approach to PEH repair. While the initial operative strategy in PEH repairs did not include sac resection, most experts now consider resection of the intramediastinal hernia sac to be a critical factor in reducing the incidence of early failure (< 6 months) from intrathoracic slippage (Watson et al. , 1999). A second critical step in the repair of PEH is the crural repair. While crural repair is uniformly performed in most series, it appears that the addition of a PTFE reinforcement mesh, following the principles of "tension-free repair", further reduces the incidence of recurrences (Frantzides et al. , 1999). A recent randomized trial by Frantzides et al. (1999) showed a significantly higher incidence of early recurrences within 6 months of surgery (16.7% vs. 0%) in the group without PTFE. While most series report high symptomatic success rates, PEH repairs are still associated with a relatively high recurrence rate. A recent report by Hashemi et al. demonstrated a recurrence rate of 42% in the patients treated laparoscopically, with more than half of the patients having few if any symptoms (Hashemi et al. , 2000). Longer follow-up will be required to determine the ideal strategy for management of these patients. 15. References
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