Laparoscopic paraoesophageal hernia repair: fundoplication is not usually indicated

Paraoesophageal hernias are an uncommon but important diaphragmatic defect due to a high prevalence of associated complications. The advent of laparoscopic surgery has popularised the surgical management of this condition, although the optimal technique has yet to be defined. The aim of this cohort study was to assess the necessity of an anti-reflux procedure in addition to the crural repair.

Details of all patients undergoing laparoscopic paraoesophageal hernia repair were collected prospectively paying particular attention to the details of the operative procedure and outcome, including the development of early complications. All patients were followed for six months and symptoms related to hernia recurrence or technical failure including dysphagia and reflux were noted.

Twenty-three consecutive patients underwent laparoscopic paraoesophageal hernia repair. The first 11 patients (Group 1) routinely underwent an additional anti-reflux procedure, whereas the later cohort (Group 2) did not (chi-squared P<0.05). At six months, nine of eleven patients in Group 1 reported dysphagia, in two cases requiring dilatation, but this complication was not seen in those in Group 2. Two patients reported reflux at six-month follow-up; this was controlled in both cases by a low dose of a proton pump inhibitor.

Laparoscopic repair of paraoesophageal hernias is an effective treatment with excellent short-term results and no recurrences. Our experience would suggest that an anti-reflux procedure is not always indicated and may indeed be detrimental to symptomatic outcome.