Methods
Patients
The charts and outcomes of 15 consecutive patients with hiatal hernias treated using a BMIV fundoplication in our Department between January 2005 and March 2011 were reviewed. The ethical review board of the University of Athens approved our study and permitted us to collect and analyze patient data. All patients agreed to participate in the study and informed consent was obtained from each patient, to publish their treatment details including intraoperative photographs. There were 11 men and 4 women with a mean age of 63 years (38–79 years). All patients reported heartburn, 4 patients reported regurgitation, while no patients experienced preoperative dysphagia. In addition, 5 patients complained of atypical GERD symptoms such as coughing, chest and abdominal pain, and bloating. Two of the patients with large paraesophageal hernias reported recurrent aspiration. Indications for surgery via a thoracic approach were GERD symptoms refractory to medical therapy and/or endoscopic findings of esophagitis in 4 patients with previous abdominal surgery and/or marked obesity, large paraesophageal hernias in 4 patients, a gastroesophageal junction over 5 cm above the hiatus irreducible in barium swallow in 2 patients and hernia recurrence after previous surgery in 5 patients. Preoperatively all patients underwent esophagogastroscopy, which revealed signs of oesophagitis in 11 out of 15, barium swallow examination, and a computed tomographic scan. 24 hour pH monitoring, was performed in patients where no paraesophageal hernia or obvious signs of moderate to severe oesophagitis were present and was abnormal in 7 out of 8 patients.
Surgical Technique
All patients had a double-lumen endotracheal tube. Before induction of anesthesia an epidural catheter was placed to facilitate postoperative pain control. The surgical approach was via a left lateral thoracotomy through the 6th or 7th intercostal space, with the patient in a right lateral decubitus position. Dissection and incision of the mediastinal pleura were performed as needed up to the level of the aortic arch. The hernial sac was dissected off the diaphragm. The esophagus was elevated using a penrose drain. Cephalad traction was placed on the esophagus and the phrenoesophageal membrane was incised circumferentially. The fundus of the stomach was mobilized, the fat pad excised, while the vagus nerves were preserved. The diaphragmatic crura (or more commonly the right and left bundles of the right crus) were then approximated posteriorly by 3–4 interrupted 0 silk sutures, which were left untied. An evaluation of the adequacy of the esophageal mobilization was then made and, if necessary, further mobilization was performed. The fundus was pulled up, 3 horizontal mattress sutures were placed 1.5–2 cm from the esophagogastric junction between stomach and esophagus to create the 270° wrap and these were then tied. Afterwards, the second row of sutures was placed 1–1.5 cm proximally so as to include the diaphragm and, after reduction of the fundus into the abdomen, these were tied also (Figure 1). Finally, the sutures between the crura were tied up to the point where a finger could pass easily through the hiatus. A pleural drainage tube was then placed and the thoracotomy closed. Analgesia was maintained with epidural bupivacaine, nonsteroidal anti-inflammatory drugs and systemic opiates, as needed. The patients were examined with an upper gastrointestinal series on the 4th postoperative day and they discharged from the hospital on the 5th or 6th postoperative day.
(Enlarge Image)
Figure 1.
Belsey Mark IV operation. Top left – Hernial sac adhering to the lung. Bottom left – Sutures placed between the diaphragmatic crura. Top right – First row of sutures between the stomach and the esophagus. Bottom right – Second row of sutures incorporating the stomach, the esophagus and the diaphragm.
Outcome Assessment
Patients' symptoms were evaluated before surgery, at 3, 6, 12 months after surgery and annually thereafter. At the time of this study on September 2011, all patients were interviewed. They were questioned about the presence, intensity (mild, moderate, severe) and frequency (daily, weekly, monthly, less frequently) of heartburn, dysphagia, regurgitation, pulmonary symptoms, nausea, vomiting, abdominal bloating, chest pain and the need for acid-reducing medications. Patients were specifically asked to describe post thoracotomy pain on a 4-point scale (1 pain free, 2 slight pain, negligible, 3 moderate pain requiring pain relief, 4 severe pain, intolerable), The Visick score, which consists of a 4- grade scale, was used to score the overall effect of surgery. All patients had esophagogastroscopy. When persistence or recurrence of GERD symptoms was noted, they were further examined with a barium swallow examination and 24 hour pH monitoring.