Open Paraesophageal Hernia Repair

The incidence of patients developing a hiatal hernia continue to increase in the United States. With the increase in the elderly population and the rise of obesity, the incidence of patients with a paraesophageal hernia (PEH) that will require surgical care will increase significantly over time, so timing of surgical correction and what approach and repair is paramount to decrease operative morbidity and mortality and to improve short-term and long-term outcomes. Surgical repair is indicated in patients with symptomatic or complications of PEH, the timing of which depends upon the acuity of presentation and significance of symptoms. Patient evaluation should include a detailed history (review old operative reports) and physical examination, and endoscopic and radiographic evaluation are warranted in patients with PEHs to maximize the best surgical treatment, approach, and type of procedure. PEHs can be repaired transabdominally or transthoracically. Even though laparoscopic approach has become the standard approach for elective and emergent PEH repair (PEHR), an open transabdominal or transthoracic approach should also be in a surgeon’s surgical armamentarium to offer to patients with complex type IV PEHs who have failed multiple abdominal PEHR, prior mesh use, or with significant obesity. Open procedures have similar associated morbidity and mortality as laparoscopic PEHR. Conversion to an open approach, transabdominal for general surgeons or transthoracic for thoracic surgeons, is warranted to improve outcomes in patients with a complex or recurrent PEH.