PRACTICE-CHANGING MILESTONES IN ANTI-REFLUX AND HIATAL HERNIA SURGERY: A SINGLE SURGEON PERSPECTIVE OVER 27 YEARS AND 1,175 OPERATIONS
Vic Velanovich*
Surgery, University of South Florida, Tampa, FL
INTRODUCTION
Since the modern era of hiatal hernia and antireflux surgery began, there has been great advances in our understanding of pathophysiology and operative technique. The purpose of this study is to review a single surgeon experience over 25 years to provide perspective on the evolution of management from seminal advances in disease understanding and operative technique.
METHODS
Patients undergoing antireflux surgery or hiatal hernia repair by a single surgeon from 12/1992 to 11/2019 were reviewed. Data collected: sex, age, type of hiatal hernia (I – IV), type of operation, adjuncts to repair, additional procedure performed during index operation and changes in preoperative evaluation or surgical management. Note was made of diagnostic or therapeutic instrumentation and procedures which changed surgical management.
RESULTS
During the time period, 1,175 operations were performed in 466 males (40.1%) and 709 females (59.9%), mean age 55.3 + 21.3 yrs. Distributions: Hernia type: I, 696 (59.2%); II-IV, 316 (26.9%); Recurrent/Re-do, 161 (13.7%). Type of operation: Laparoscopic Nissen fundoplication: 701 (59.7%); converted to open Nissen fundoplication: 54 (4.6%); planned open Nissen fundoplication: 122 (10.4%); laparoscopic Toupet fundoplication: 119 (10.1%); converted to open Toupet fundoplication: 12 (1.0%); planned open Toupet fundoplication: 22 (1.9%); Collis-Nissen/Toupet fundoplication: 44 (3.7%); hiatal hernia repair without fundoplication (laparoscopic and open): 38 (3.2%) (includes 11 antireflux device study patients); total incisionless fundoplication (TIF, Esophyx): 35 (3.0%); hiatal hernia repair with Heller myotomy and Dor fundoplication: 10 (0.9%); transthoracic Belsey Mark IV: 2 (0.2%); Laparoscopic hiatal hernia repair with magnetic sphincter augmentation: 16 (1.4%). Mesh onlay, 181 (15.4%). Additional procedures, 209 (17.8%). During this time, the following practice changing advancements have occurred: adoption of laparoscopic antireflux surgery, 48 hour pH monitoring, high-resolution manometry, tailoring of fundoplication type, energy sources for division of tissue and hemostasis, pyloroplasty for associated symptomatic gastroparesis, the rise and fall of endoluminal therapies, mesh reinforcement, abandonment of short gastric vessel division, and magnetic sphincter augmentation.
CONCLUSIONS
Over the last 27 years since 1992 a number of practice-changing advances have been made. These have led to changes in technique and operation selection of antireflux and hiatal hernia surgery.
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