Laparoscopic paraesophageal hernia repair: critical steps and adjunct techniques to minimize recurrence.

INTRODUCTION: Laparoscopic repair of paraesophageal hernias (PEH) is associated with a high objective hernia recurrence rate. Tension is a key factor in the repair of any hernia, and tension is a cause for hernia recurrence.
METHODS: This is a review of my current technique for PEH repair, and represents the culmination of years of experience and modifications in an effort to minimize objective hernia recurrence rates in my own practice.
RESULTS: There are 4 critical steps that must be part of every PEH repair in my opinion. These are excision of the hernia sac, mediastinal esophageal mobilization, crural repair, and fundoplication. Tension on the repair comes in the form of axial tension related to esophageal shortening and lateral tension related to widely splayed crura. Axial tension is addressed with a Collis gastroplasty, while lateral tension requires a right, left, or bilateral crural relaxing incision. The crura should not be bridged with mesh, rather a relaxing incision allows primary crural approximation even with very splayed crura. The primary crural closure is routinely reinforced with absorbable mesh. Follow-up with upper endoscopy or videoesophagram shows a low recurrence rate using these 4 steps and the adjunct techniques to reduce tension when necessary. DISCUSSION: Efforts to reduce the objective recurrence rate after laparoscopic PEH repair should focus on minimizing tension with the use of a Collis gastroplasty and crural relaxing incisions when necessary. Similar to hernias at other sites, the use of mesh likely is another adjunct step that will improve outcomes with PEH repair, but to avoid erosion synthetic mesh should be avoided.