Abstracts
2001 Digestive Disease Week

# 225 Laparoscopic Management of Giant Type III Hiatal Hernia and Short Esophagus: Objective Follow-up at Three Years
Blair A. Jobe, Ralph W. Aye, Clifford W. Deveney, Lucius D. Hill, Seattle, WA, Portland, OR

Recent studies have called into question the durability of a laparoscopic approach to type III hiatal hernia repair. The aim of this study was to evaluate the long-term effectiveness of the laparoscopic Hill procedure for the treatment of Giant hiatal hernia with or without short esophagus. As part of a prospectively gathered database, 52 patients underwent laparoscopic repair of a type III hiatal hernia. Repair included hernia reduction, sac excision, primary crural closure, and valvuloplasty via posterior fixation of the gastroesophageal junction (GEJ) to the preaortic fascia. Intraoperative manometry was used to calibrate repair tightness. The presence of a short esophagus was determined prior to valvuloplasty when, despite extensive mediastinal dissection, there was difficulty delivering the GEJ subdiaphragmatically. No esophageal lengthening procedures were performed. Late symptomatic followup and a satisfaction questionnaire were completed in 71%(37/52) of patients at a mean of 39 months. Video esophagrams were completed in 65%(34/52) of patients at a mean of 37 months after repair. The hernia recurrences were categorized under the following headings: Type I- GEJ above diaphragm without paraesophgeal component, Type II- Properly positioned GEJ with paraesophageal component, and Type III- GEJ above the diaphragm with a paraesophgeal component. Eighty-one percent of patients were without any adverse symptoms and 87% were very satisfied or satisfied with the outcome at 39 months followup. Heartburn and regurgitation requiring medical therapy was present in 19%(7/37)of patients. On followup video esophagram, recurrent hernia had occurred in 32%(11/34)of patients, 36%(4/11)of whom were asymptomatic. Of the 11 recurrences, there were 3 type I, 4 type II, and 4 type III. The incidence of short esophagus was 19%(10/52)overall. Short esophagus was present in 9%(1/11)of the recurrence group, and in 21%(5/23)of patients with an intact repair on esophagram. Despite long-term relief of symptoms and a high degree of patient satisfaction, laparoscopic repair of type III hiatal hernia is associated with a high recurrence rate. As symptoms are a poor indicator of recurrence, all patients (open and laparoscopic) should be followed with video esophagram. The presence of short esophagus does not appear to play a role in recurrence when posterior fixation of the GEJ is used.