Ann Thorac Surg 2001;72:1129
© 2001 The Society of Thoracic Surgeons
Invited commentary
Mark D. Iannettoni, MDa
a Section of Thoracic Surgery, University of Michigan, 1500 E Medical Center Dr, 2120 Taubman Center, Box 0344, Ann Arbor, MI 48109, USA
e-mail: mdi{at}umich.edu
The article by Dahlberg and associates represents an important contribution to the literature of a difficult problem on a controversial topic. It is important because this article discusses not whether laparoscopic repair of large esophageal lesions can be done, but whether or not they should be done. The group at the Mayo Clinic has clearly demonstrated that laparoscopic repair of a large paraesophageal hiatal hernia is possible, but more importantly, they have reported with honesty and integrity the early and intermediate results. Initial reports of laparoscopic surgery for this entity indicate only that the procedure is able to be done in almost all patients, however, only with few exceptions are there any long-term results reported for open repairs of paraesophageal hernias let alone laparoscopic approaches. Their results show that there is a significant number of intraoperative complications with this procedure even in the most experienced of hands. A recurrence rate of 4 patients was seen, however, only 22 of the 35 patients in the study were evaluated with a postoperative barium swallow. This is significantly higher than reported for transthoracic repair of a paraesophageal hiatal hernia. The overall functional results were similar to other large series, since many of these patients have abnormal gastric emptying and esophageal motility prior to operation.
The key points identified for recurrence or failure with this technique are: (1) inadequate crural closure; (2) inadequate excision of the sack and mobilization of the stomach; and (3) difficulty with crural reapproximation. It is important to realize that this is an early report involving a formidable problem with a new technique. Like any new procedure, this will require a significant learning curve which should be carried out only by those with the ability to perform advanced laparoscopic surgery as well as the ability to treat the complications as well as the expertise to perform esophageal reconstruction. It is only with this honest and unbiased reporting of experience as exemplified by the Mayo group that we will truly learn whether this is technology advancing patient care or simply the advancement of technology for technology’s sake.
Related Article
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Laparoscopic repair of large paraesophageal hiatal hernia
- Peter S. Dahlberg, Claude Deschamps, Daniel L. Miller, Mark S. Allen, Francis C. Nichols, and Peter C. Pairolero
Ann. Thorac. Surg. 2001 72: 1125-1129.
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