Laparoscopic/Thoracoscopic surgery for complex non axial hiatus hernia.

Background: In order to demonstrate the feasibility and the corner stones of the minimally invasive surgical technique for the treatment of paraoesophageal and massive incarcerated hiatus hernia we show the case of a 66 years old woman with 20 years history of GORD symptoms, dyspnoea with orthopnea, erosive oesophagitis and recurrent sideropenic anaemia. Barium swallow shows a paraoesophageal hiatus hernia. We present a second case of a 56 years old man complaining severe GORD symptoms since 6 years with painful dysphagia, erosive oesophagitis. Barium swallow shows a non-reducible 10 cm diameter massive incarcerated hiatus hernia. Methods: The steps of the surgical procedure are: 1) complete resection of the hernia sac and fat pad with preservation of the vagus nerves, 2) localization of the position of the GO junction with respect to the apex of the hiatus with a combined endoscopic–laparoscopic procedure, 3) measurement of the length of the esophageal submerged segment, 4) isolation of the mediastinal oesophagus, 5) Collis gastroplasty in case of short oesophagus , 6) hiatus alloplasty, 7) Nissen floppy fundusplication. Results: After maximal oesophageal mobilization , in the first patient the GO junction was placed 2,5 cm below the hiatus and a standard fundusplication was performed , in the second case the GO junction was placed across the hiatus and a combined laparoscopic-left thoracoscopic Collis gastroplasty was necessary. Conclusions: The minimally invasive approach for complex hiatus hernias appears feasible. 15 patients (mean age 65.8 ± 11.7 years) underwent laparoscopic Nissen and 14 (mean age 66.5 ± 11.7 years) thoraco-laparoscopic Collis-Nissen. Median follow up was 21 months (r. 6-58) with 1 mortality in each group (pulmonary embolus and Collis fistula). Results were excellent and good in 93%, and fair or poor in 7%.