Novel combined VATS/laparoscopic approach for giant and complicated paraesophageal hernia repair: description of technique and early results



The laparoscopic approach for repair of giant and/or recurrent paraesophageal hernias (PEH) is challenging, due to limited access to the dissection of the hernia sac into the proximal mediastinum and esophageal mobilization through the diaphragmatic hiatus. An esophageal lengthening procedure is often necessary, due to the difficulty in obtaining adequate intra-abdominal esophageal length. We, therefore, developed a VATS and laparoscopic technique, which allows for safe and extensive thoracic dissection and intra-abdominal gastric fixation and cruroplasty, yet preserving the benefits of minimally invasive surgery.


We use a standard VATS approach. The hernia sac, optimally visualized, is dissected posteriorly from the thoracic aorta, inferiorly from its diaphragmatic attachments, anteriorly from the pericardium, and laterally from the mediastinal pleura. The esophagus is completely mobilized up to the aortic arch, and the anterior vagus nerve is released from its bronchial branches. The hernia sac is then opened, dissected, and completely removed. The hernia content is then reduced into the abdomen laparoscopically, the short gastric vessels are divided and the gastric fundus is completely mobilized. The hiatus is closed with interrupted sutures, and the cruroplasty is buttressed with a biological mesh. A floppy Nissen or a partial fundoplication and a gastropexy are done for reflux control and gastric fixation.


From January 2012 to January 2014, we treated 18 patients (7 with type III PEH and 11 with type IV) with the above-described procedure. Six patients had previous history of antireflux surgery. We performed a planned laparotomy instead of laparoscopy in two patients, who needed concurrent repair of complex incisional hernias. We did not need esophageal lengthening procedures, nor experienced damages to thoracic structures in any patient.


Our newly developed surgical approach has proven to be safe and feasible. This technique represents a good option for treatment of giant and complicated PEH.

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Mr. Edwin Lewis and Mrs. Jane Blaustein provided generous support of Dr. Lidor’s Department of Surgery Research Fund.


Daniela Molena, Benedetto Mungo, Miloslawa Stem, and Anne O. Lidor have no conflicts of interest or financial ties to disclose.

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Corresponding author

Correspondence to Daniela Molena.

Additional information

Presented at the SAGES 2014 Annual Meeting, April 2–5, 2014, Salt Lake City, Utah.

Electronic supplementary material

Below is the link to the electronic supplementary material.

VIDEO 1: VATS exploration and hernia sac dissection (WMV 58568 kb)

VIDEO 2: Esophageal dissection and release of the anterior vagus nerve from its bronchial branches (WMV 122658 kb)

VIDEO 3: Hernia sac opening and resection; Laparoscopic reduction of hernia contents and esophageal length assessment (WMV 40514 kb)

VIDEO 4: Laparoscopic crural repair and fundoplication confectioning (WMV 59296 kb)

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Molena, D., Mungo, B., Stem, M. et al. Novel combined VATS/laparoscopic approach for giant and complicated paraesophageal hernia repair: description of technique and early results. Surg Endosc 29, 185–191 (2015).

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  • Thoracoscopy
  • Surgical
  • Oesophageal
  • Paraesophageal hernia
  • Laparoscopy