Tension-free hiatoplasty, gastrophrenic anchorage, and 360° fundoplication in the laparoscopic treatment of paraesophageal hernia

In our initial experience of four cases from March to November 1994, large paraesophageal hernias were repaired by conventional primary closure of the hiatus with interrupted, nonabsorbable sutures, adding a 360 degrees fundoplication. In all four cases the hernia recurred. Subsequently, we modified the procedure. The technique and results are described. From March 1995 to May 1998, 12 patients with paraesophageal hernia (4 following a previous Nissen procedure) underwent elective laparoscopic repair. In all patients a "tension-free" hiatoplasty and a floppy 360 degrees fundoplication were performed. The hiatal defect was repaired with a polypropylene mesh, fixed to the diaphragm by staples. A gastrophrenic anchorage procedure was added in the eight patients undergoing surgery for the first time, utilizing the peritoneum of the hernia sac. There were no conversions to open surgery or intraoperative complications. Two patients developed postoperative pleural effusion, which was treated medically. Mean hospital stay was 5 days. Three patients developed postoperative transient dysphagia to solid food that lasted 10 days. At a mean follow-up of 22.7 months (range 1-40), all patients are asymptomatic without dysphagia, reflux, or hernia recurrence. Laparoscopic "tension-free" hiatoplasty, 360 degrees fundoplication, and anterior gastrophrenic anchorage are effective in the treatment of large paraesophageal hernias.