Paraconduit hernia after minimally invasive esophagectomy

Introduction

Background

The occurrence of paraconduit hernias, while rare, has garnered increased attention following the introduction of minimally invasive esophagectomy (MIE) and robotic-assisted minimally invasive esophagectomy (RAMIE). This shift in focus arose as the development of new MIE and RAMIE techniques revealed a significant rise in the incidence of paraconduit hernias (1,2). Not all paraconduit hernias necessitate surgical intervention. Many are detected incidentally and remain asymptomatic, making them amenable to a watch-and-wait approach. Strict adherence to specific criteria for paraconduit hernia repair is imperative, given high morbidity (25–35%) and recurrence rates reported following repair (2-4).

Rationale, knowledge gap, and objective

Clear guidelines for managing paraconduit hernias after MIE and RAMIE are still lacking, with only limited studies published thus far. Our article aims to consolidate and analyze recent research findings, providing surgeons with a comprehensive overview of the current understanding of paraconduit hernias after MIE and introducing novel approaches for their management.

Paraconduit herniation after MIE

Incidence of paraconduit hernia after MIE

The reported incidence of paraconduit hiatal hernia (HH) after MIE varies widely in the literature, ranging from 0% to 26.3%, encompassing studies of paraconduit hernia after laparoscopic MIE, laparoscopic and thoracoscopic MIE, and RAMIE. Noble and colleagues reported the lowest incidence at 0% among 53 patients undergoing thoracolaparoscopic esophagectomy, while Willer and colleagues described the highest incidence at 26.3% among 19 patients undergoing McKeown (3-incision) MIE (2,5,6). Additionally, single-institution series by Bronson and colleagues and Ullua Severino and colleagues reported hernia rates of 8%, with symptomatic patients comprising 44% and 69% of the total cases, respectively (7,8).

Lung and colleagues evaluated a large, single-institution series of 347 patients who underwent esophagectomy (39% MIE and 61% open or hybrid esophagectomy) from 2007 through 2017 and published their findings in 2021. Paraconduit HH developed in 15% of the patients after MIE as compared with 8% after open or hybrid esophagectomy (P=0.03); 36% of the paraconduit HH detected after esophagectomy were symptomatic, with a median time to diagnosis of 258 days (range, 4–4,368 days). Most of the symptomatic hernias occurred after MIE (77%) (1). A meta-analysis of 26 studies published between 1985 and 2015 found that the pooled incidence of symptomatic HH was 4.5% after MIE, as compared with 1% after open esophagectomy (2). Similarly, a meta-analysis of 27 studies published from 1999–2021 found a pooled incidence of HH of 5.3% after MIE and 1.5% after open esophagectomy (3). Because asymptomatic paraconduit HHs may be missed in the absence of imaging or without interpretation by a radiologist familiar with post-esophagectomy anatomy, the true incidence of post-MIE hernias is likely to have been underestimated (1,9,10).

Additionally, the incidence of recurrence of paraconduit hernia after repair is relatively high, occurring in ~30% of patients (1,4,8,10-13). The meta-analysis of Oor and colleagues found a pooled recurrence rate of 14%, which was calculated from analysis of 125 patients in 11 studies (2).

Factors contributing to the development of paraconduit hernia

Several retrospective studies and meta-analyses have highlighted multiple contributing factors associated with the development of paraconduit hernia. MIE has been consistently linked to a higher incidence of paraconduit hernia as compared with open surgery (1-4,6,11,14). The odds of a paraconduit hernia after MIE have been reported as 1.5–4.3 times higher than after open esophagectomy (10,13,15,16). Reduced peritoneal adhesion formation in the hiatal region, possible hiatus dilation due to insufflation, and more extensive hiatus widening during mediastinal dissection are commonly cited factors hypothesized to contribute to this increased incidence (1,4,17-19). Additionally, preexisting HH, prior to MIE, is strongly linked with an increased risk of developing a paraconduit hernia (16,20). In a large, single-institution study, tumor location at the gastroesophageal junction and previous hiatus surgery were also strongly associated with increased risk of post-esophagectomy paraconduit hernia (16). Patients who develop a paraconduit hernia after MIE are more likely to be younger patients and more likely to experience tumor recurrence as compared with other post-esophagectomy patients, which is consistent with the documented increased risk of herniation over time (16,21,22). High body mass index may be protective against paraconduit herniation (1,4,23). Furthermore, there is some evidence that neoadjuvant radiation therapy may be somewhat protective against the development of paraconduit hernia after esophagectomy, possibly due to the impact of inflammation and adhesion formation following neoadjuvant treatment. Other studies have shown the converse association, however, and suggested that neoadjuvant therapy increases the risk of developing a paraconduit hernia (1,16,23,24). Thus, the relationship between neoadjuvant treatment and post-esophagectomy paraconduit herniation remains unclear.

Clinical features and presentation of paraconduit hernia

Patients with paraconduit hernia may present with a wide range of symptoms, which can vary from being asymptomatic to experiencing nausea, abdominal pain, cough, respiratory complaints, dysphagia, and obstructive symptoms (2,21). The standard diagnostic tool for paraconduit HH is typically a computed tomography (CT) scan. However, a considerable percentage of paraconduit HH cases may go undetected by radiologists on routine CT scans, and this presents a significant challenge. When Ganeshan and colleagues reviewed follow-up, cross-sectional CT imaging of all patients who had undergone esophagectomy at their institution over a 7-year period, only 16% of the paraconduit HH cases that they identified were diagnosed prospectively by the institution’s radiologists, highlighting the difficulty in accurately diagnosing postoperative paraconduit HH (9). Similarly, in Lung’s series, 58% of the paraconduit HHs detected after esophagectomy in a retrospective review of cross-sectional imaging were noted on the original radiology reports (1). These studies highlight the need for specialized thoracic radiology expertise when evaluating post-esophagectomy anatomy and support the continued involvement of thoracic surgeons in post-esophagectomy surveillance. This is particularly true when the need to distinguish between redundant conduit and a paraconduit hernia arises, as the management of these conditions will be different.

Paraconduit hernia repair

Indications for paraconduit hernia repair

Numerous studies have explored the repair of post-MIE paraconduit hernias, with findings supporting repair in symptomatic patients, if the patient is a candidate for surgery (25,26). Whether or not malignant disease has progressed should also be considered.

Multiple studies have assessed repair of asymptomatic paraconduit hernias, and few surgeons recommend repairing all asymptomatic paraconduit HH after MIE (11,27). For instance, a study done by Barron and colleagues found that the incidence of paraconduit hernia increased with time after esophagectomy, but that emergency complications developing from an asymptomatic paraconduit hernia were rare. Thus, their team would offer a watch-and-wait approach while considering the repair electively in patients with persistent symptoms (22). Significant morbidity (25%) is associated with paraconduit hernia repair; atrial fibrillation, pneumonia, pleural effusion, empyema, wound infection, and chylothorax have been commonly reported. Thus, the risks and benefits of the procedure and the patient’s life expectancy should be taken into account before proceeding with repair.

The herniated contents do not dictate repair, per se, but symptomatic hernia requiring repair have most frequently been reported to contain colon or multiple organs. For example, in Barron’s study, 37 paraconduit HHs were detected by CT in 1,214 patients after MIE; 21 hernias (57%) contained colon, 7 hernias (19%) contained pancreas, and 9 hernias (24%) contained multiple organs. Most (30 of the 37 paraconduit HHs) were asymptomatic and were managed nonoperatively. Of the 7 persistently symptomatic patients, 6 had undergone or were scheduled for repair and 1 was unfit for surgery. All of these patients had either herniation of the colon or multiple organs, and none had herniation of only the pancreas (22). Lung’s large study identified 36 patients with paraconduit HH after esophagectomy—20 after MIE and 16 after open or hybrid esophagectomy. Herniated contents were colon in 67%, small bowel in 8%, pancreas in 11%, and more than 1 organ in 14%. Three of 23 asymptomatic patients and 11 of 13 symptomatic patients underwent repair. In the asymptomatic patients, recurrent disease (cancer) was a factor in the decision not to repair the hernia in 14 patients. All patients with multiple herniated organs underwent repair (1).

Methods for paraconduit hernia repair

The foundational principles of the paraconduit hernia repair are safe reduction of the hernia contents without injuring the conduit or its blood supply and tension-free narrowing of the hiatus to prevent future recurrences. Although there is no consensus on the best approach for paraconduit hernia repair, most expert thoracic surgeons recommend a minimally invasive abdominal approach, either laparoscopic or robotic assisted. The reduction of the herniated contents back into peritoneal cavity is usually challenging, and simply attempting to forcefully pull the content down usually leads to bowel injury. The authors recommend making a small incision at the apex of left crus to widen the hiatus to aid in reduction of the contents back into the peritoneal cavity. This incision is repaired when performing the left cruroplasty as part of narrowing the hiatus.

Various approaches for paraconduit hernia repair exist, one of which was outlined by Benjamin and colleagues (28), where the hiatus is primarily closed by bringing together the diaphragmatic crura in front of the conduit with sufficient laxity to enable a tension-free repair. Depending on the surgeon’s judgment, in patients with large defects, regardless of whether primary repair was feasible, a bio-absorbable mesh was placed to reinforce the repair and prevent recurrence (28). Irrespective of the approach, most authors recommend safe reduction of the herniated contents, narrowing the hiatus, and suturing the conduit to the hiatus.

Mesh reinforcement is not used in all patients and its utility remains controversial. In a systematic review by Oor and colleagues, mesh was used to achieve adequate crural closure during paraconduit hernia repair in a subset of patients in 14 of the 26 studies reviewed (2). In one of the most recent studies, published in 2023, Barron and colleagues used acellular matrix mesh in 50% of their repairs (2 out of 4 patients) (22). Other studies have raised concerns regarding the potential risks of nonabsorbable mesh, such as erosion into the vascular conduit or damage to the conduit’s vascular supply (14,24).

Operative planning for repair can be done based on clinical and radiological findings. The basic tenets for repair remain unchanged: reduction of the hernia contents, excision of the sac when present, and tension-free approximation of the crus with non-absorbable suture. Bioabsorbable mesh can be used selectively for crural reinforcement. Extreme care must be taken to identify and preserve the gastroepiploic vascular pedicle supplying the conduit and to prevent twisting or excessive tension on the conduit during repair. Most paraconduit hernias can be approached through the abdomen and repaired using a minimally invasive approach. A combined chest and abdominal approach has been used in some patients with large paraesophageal hernias to facilitate reduction and repair (29,30). We have never encountered a scenario necessitating a combined approach to repair a paraconduit hernia, however. We cut the crura and widen the opening to allow sufficient access from the abdomen. After the paraconduit HH is reduced, we complete a primary repair of the crura.

We recently reported a novel robotic approach for paraconduit hernia repair that utilizes a falciform ligament patch to repair the defect (Figure 1) (31). This approach follows the basic principles of paraconduit hernia repair and is particularly helpful when the crus cannot be easily closed. We prefer to use a robotic approach via the abdomen. The first step is to reduce the hernia by simply pulling the contents back to the peritoneal cavity. If excessive force is needed, then we recommend making a small incision at the apex of the left crus to aid in this process. Once the contents are reduced, we perform a left cruroplasty by suturing the upper third of the left crus to the anterior part of the hiatus with one or two pledgeted 0-Ethibond stitches. Subsequently, we place a few interrupted stitches between the conduit and the hiatus. Once we satisfactorily reduce the hiatus, we robotically mobilize the falciform ligament on a vascularized pedicle to reinforce the hiatal closure. (Figure 2). Others have similarly used a falciform ligament patch to buttress the crura during laparoscopic hernia repair with good outcomes and no recurrences in 18 patients at a median follow-up of 8 months (range, 3–15 months) (32). We believe this is a promising alternative to mesh or primary repair only when treating patients with paraconduit hernia.

Figure 1 Use of a falciform ligament patch during paraconduit hernia repair to discourage hernia recurrence. After the herniated conduit is reduced, the falciform ligament is mobilized. Reprinted from Kashyap et al. (31) ©2024, with permission from Elsevier.

Figure 2 Construction of a falciform ligament patch during paraconduit hernia repair. The mobilized ligament is sutured to the crus.

Prevention of paraconduit hernia during index operation

There is currently no universally recognized standard technique for preventing paraconduit hernia. There are strategies, which have been nicely summarized by Benjamin and colleagues (28), such as limiting hiatal size, and preserving the crura, as described by Vallbohmer, Price, and their colleagues (26,27). Further options could include securing the stomach anterior to the hiatus, mobilizing the gastrocolic ligament to prevent tethering of the colon, and suturing the conduit to the crura, which can be done thoracoscopically or from the abdomen (4,33).

Although no specific strategies during the index MIE operation have been proven to prevent paraconduit hernia, based on our experience, we recommend recognition and complete reduction of preexisting hiatal hernia with excision of the sac and snug closure of the widened hiatus with non-absorbable suture. This must be done with care and judgement to avoid very tight closure, which may lead to difficulty in extracting the conduit and specimen up to the chest during the thoracic phase of the MIE. We also recommend placing a non-absorbable suture securing the conduit to the diaphragm at the lowest possible point in the chest. This is usually done after the creation of the anastomosis from the chest.

Further investigation and comparative studies are necessary to determine the efficacy and optimal approach among these options. In patients with preexisting HH, some experts recommend a preventative approach involving primary closure with mesh reinforcement sutured to the gastric wall (20). We have not used mesh reinforcement in our patients.

Conclusions

In conclusion, post-esophagectomy paraconduit HH, although rare, has become more prevalent with the adoption of MIE and RAMIE. Therefore, further research aimed at understanding paraconduit hernia prevention, early detection, and management is important. Awareness of predisposing factors for paraconduit hernia and adherence to recommended techniques are crucial to successful prevention and repair. Additionally, addressing the knowledge gap in diagnosing paraconduit hernia highlights the necessity for specialized radiologists experienced in imaging after thoracic surgery and continued involvement of thoracic surgeons in surveillance of post-esophagectomy patients. Moving forward, continued investigation is needed to develop comprehensive guidelines and innovative approaches for the management of paraconduit hernia.

Acknowledgments

We thank Shannon Wyszomierski, PhD for editorial assistance in the preparation of this review.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Raul Caso and John F. Lazar) for the series “Challenging Robotic Foregut and Diaphragm Procedures” published in Journal of Visualized Surgery. The article has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-7/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-7/coif). The series “Challenging Robotic Foregut and Diaphragm Procedures” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Publication of this study and accompanying images does not require patient consent as it does not involve patient identifiable information.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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