Laparoscopic repair of hiatal hernia after esophagectomy.

BACKGROUND: Herniation of abdominal contents via the diaphragmatic hiatus is a potentially life-threatening complication of esophagectomy. Mounting evidence suggests that hiatal hernias are more common following minimally invasive esophagectomy. Therefore, post-esophagectomy hiatal hernia and its treatment bear increasing significance. METHODS: We retrospectively reviewed the records of five patients with hiatal hernia following esophagectomy over a 5-year period. RESULTS: Successful laparoscopic reduction of a post-esophagectomy hiatal hernia was done without mesh reinforcement in three patients. One patient underwent mesh reinforcement. One patient was found to have carcinomatosis upon laparoscopic inspection, and repair of the hiatal hernia was abandoned. There were no perioperative deaths or complications. One patient developed a recurrent hiatal hernia 14 months after repair of the initial hiatal hernia. Patients were discharged within a mean of 1.75 days after surgical repair. DISCUSSION: We have successfully used laparoscopy to treat hiatal hernias after esophagectomy. The benefits conferred by laparoscopy, including better visualization of the right gastroepiploic artery supplying the gastric conduit, minimally invasive evaluation of the field for metastasis, and shorter recovery time, make it our favored approach. Here, we describe our experience with hiatal hernia following esophagectomy and our operative technique.

Laparoendoscopic transgastric resection of a submucosal mass at the gastroesophageal junction.

INTRODUCTION: Traditional management of gastric submucosal lesions usually involves wedge resection. However, lesions close to the gastroesophageal junction are difficult to manage with wedge resection without compromising the lower esophageal sphincter. This video highlights an interesting combined laparoscopic and endoscopic technique for safe resection of a submucosal lesion adjacent to the gastroesophageal junction. METHODS: A 66-year-old male was evaluated by gastroenterology for melena. Upper endoscopy with subsequent endoscopic ultrasound demonstrated a 2-cm submucosal lesion adjacent to the gastroesophageal junction. Biopsies were indeterminate, and the remainder of his workup was negative. A combined laparoendoscopic technique was utilized to safely resect the lesion while protecting the gastroesophageal junction. This was accomplished using three 5-mm trocars placed directly through the abdominal wall into the stomach using endoscopic guidance. All muscle layers were resected en bloc with the specimen, leaving the serosa intact. RESULTS: The patient did well and was discharged home on postoperative day 1. Final pathology demonstrated a leiomyoma with negative margins. CONCLUSION: Submucosal lesions adjacent to the gastroesophageal junction can be safely and effectively managed using a laparoendoscopic approach. This technique provides improved visualization and facilitates an adequate resection compared to endoscopy or laparoscopy alone.