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Early Surgical Outcomes for Type II and III Paraesophageal Hernia Is Dependent Upon the Surgical Approach
Craig P. Fischer, University of Texas - Houston, Houston, TX

Recent studies have indicated that laparoscopic repair of type II and type III paraesophageal hernias is safe and equivalent to traditional repair. We report a survey of in hospital morbidity and mortality associated with repair via the transabdominal, laparoscopic and transthoracic approach at an urban academic medical center.

METHODS. Between July 1998, and October 2004, 51 patients underwent surgical repair for type II and III paraesophageal hernia. Three primary approaches have used by surgeons in this institution – the transabdominal(TA), laparoscopic(LA) and transthoracic (TT) via left thoracotomy. Surgeon preference, and not preoperative factors determined the surgical approach. A retrospective chart review of 30 day in-patient morbidity and mortality was undertaken. RESULTS. Length of stay was 10.8, 6.45 and 10.2 days for the TA, LA and TT groups respectively (table 1). Recurrent hernia was documented in hospital in 8.8%, 9.5% and 0% in the TA, LA and TT groups. Symptomatic recurrent hernia was noted in 8.8%, 9.5% and 0% respectively. Intraoperative complications were noted in 16%, 38% and 5.5% in the TA, LA and TT groups. Esophageal leak was demonstrated in 8.8%, 19% and 0% respectively. The 30 day in-hospital mortality was 8.8 %, 19% and 0% for the TA, LA, and TT groups. CONCLUSIONS. Complications including death was more frequent in patients undergoing laparoscopic repair of type II and III paraesophageal hernias. Laparoscopic repair of type II and III paraesophageal hernia is a challenging operation associated with significant morbidity and mortality. Evolution of the laparoscopic technique, evaluation of indications for surgery and consideration of open transthoracic approach in high risk patients will improve early surgical outcomes in this challenging group of patients. Table 1 In-Hospital Morbidity and Mortality, Paraesophageal Hernia Repair by Surgical Approach

	Number of Patients	Average LOS	Recurrent Hernia*	Symptomatic Recurrent Hernia**	Intraoperative Complications***	Esophageal Leak	30 Day Morality
Open Transabdominal	12	10.8	1/12 (8.8%)	1/12 (8.8%)	2/12 (16%)	1/12 (8.8%)	1/12 (8.8%)
Laparoscopic	21	6.4	3/21 (14.3%)	2/21 (9.5%)	8/21 (38%)	2/21 (9.5%)	4/21 (19%)
Open Transthoracic	18	10.2	0/18 (0%)	0/18 (0%)	1/18 (5.5)	0/18 (0%)	0/18 (0%)

*As demonstrated by Upper GI study, ** defined as recurrent dysphagia or other symptoms of paraesphageal hernia, *** defined as esophageal tear, splenic injury, or crural tear.

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