International Society For Minimally Invasive Cardiothoracic Surgery

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Open Versus Minimally Invasive Hiatal Hernia Repair After Esophagectomy
Tamar Nobel, Hari Keshava, Manjit Bains, David Jones, Daniela Molena.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.

Background: There is a paucity of data on management of hiatal hernia after esophagectomy; however, incidence of this complication is rising in the era of minimally invasive esophagectomy (MIE). Repair is a technically complex procedure with reported high morbidity. It is unknown whether the minimally invasive approach to hiatal hernia repair after esophagectomy has better outcomes than the open approach. Methods: Patients that underwent minimally invasive hiatal hernia repair after esophagectomy between 1995-2018 were identified from a prospectively maintained institutional database. Demographic, clinicopathologic, treatment and outcomes were compared between patients that underwent open versus minimally invasive hiatal hernia repair. The Chi Square and Wilcoxon rank sum tests were used to compare categorical and continuous variables. Results: There were 43 patients identified that underwent hiatal hernia repair during the study period (43/2141, 2%). Of these, 9 had open repair and 34 had minimally invasive repair. The majority of hernias were in the left chest and most frequently contained colon (74%) or small intestine (40%). Median time from esophagectomy to repair was 1.2 years (range, 3 days-14.8 years). However, 6/16 (38%) of open esophagectomy patients underwent repair within 30 days of surgery as compared to no MIE patients. Comparison of open versus minimally invasive repair is presented in Table 1. Patients that underwent open repair had a trend toward shorter operative time but significantly higher median estimated blood loss (p=0.044). The open repair group had a trend toward a higher postoperative complication rate. There were 8 (21%) patients that underwent reoperation for hernia recurrence, 1 in the open and 7 in the minimally invasive group. In the minimally invasive group, one patient required conversion to open to successfully reduce incarcerated bowel, and one mortality occurred in a patient that underwent emergent repair. Furthermore, one patient required reoperation within the 30-day postoperative period for hernia recurrence. Conclusion: Minimally invasive hiatal hernia repair after esophagectomy is feasible with lower intraoperative blood loss and shorter length of stay than the open approach. However, it is still associated with significant morbidity and possibly higher recurrence than open repair.LEGEND: Table 1. Comparison of characteristics between open and minimally invasive hiatal hernia repair

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