Management of giant paraesophageal hernia

Management of giant paraesophageal hernia remains one of the most difficult challenges faced by surgeons treating complex benign esophageal disorders. These large hernias are acquired disorders; therefore, they invariably present in elderly patients. The dilemma that surgeons faced in the open surgical era was the risk of open surgery in this elderly, sick patient population versus the life threatening catastrophic complications, nearly 30% in some series, observed with medical management. During the 1990s, it was clearly recognized that laparoscopic surgery led to decreased morbidity with a quicker recovery. This has lead to a 6-fold increase in the surgical management of giant paraesophageal hernias over the last decade compared to a period of five decades of open surgery; however, this has not necessarily translated into better outcomes. One of the major issues with giant paraesophageal hernias is recognizing short esophagus and performing a lengthening procedure, if needed. Open series which report liberal use of Collis gastroplasty leading to a tension-free intraabdominal fundoplication have shown the best anatomic and clinical outcomes. As we duplicate the open experience laparoscopically, the principle of identifying a shortened esophagus and constructing a neo-esophagus must be honored for the success of the operation. The benefits of laparoscopy are obvious but should not come at the cost of a lesser operation. This review will illustrate that laparoscopic repair of giant paraesophageal hernia at experienced centers can be performed safely with similar outcomes to open series when the fundamental principles of the operation are maintained.