A history and recent advancements Ben Gerber MD FACS 562023 Accreditation Boone Medical Center is accredited by the Missouri State Medical Association to provide continuing medical education for physicians ID: 1000589
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1. Surgical Management of Hiatal Hernia:A history and recent advancementsBen Gerber MD FACS5/6/2023Accreditation: Boone Medical Center is accredited by the Missouri State Medical Association to provide continuing medical education for physicians.Credit: Boone Medical Center designates this live activity for a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity.
2. Faculty Disclosures: Dr. Ben Gerber has disclosed he has no financial interest or other relationship with the manufacture(s) of the product(s) or any of the services he intends to discuss. There is no conflict of interest. Planners (Patrick Finney, Kyndal Riffie & Jarod Lafrenz) Disclosures: All event planners have disclosed that none have any financial interest or other relationship with the manufacture(s) of the product(s) or any of the services to be discussed. There is no conflict of interest. There is no commercial financial support for this live eventDisclosures
3. Clinicians will learn:Options for more durable hiatal hernia repair surgery. Signs of symptomatic hiatal hernia to refer to surgery.The history of prior surgical repairs and how modern repair is different. Learning Objectives
4. Example caseHiatal Hernia HistoryIntro
5. 50 y/o F with yyy years of GERD, managed with PPI and dietary and lifestyle modificationsSymptoms have been gradually worsening in severity, now poorly controlled on PPI.Prior EGD, and more recent EGD demonstrate hiatal hernia increasing in size. Now also with worsening control of her COPDExample: Mrs. CH
6. Work UpShe already had an EGD, review those pictures and biopsies if done. If there is a CT or Esophagram available, also review those.She needs esophageal Manometry.
7. Day of SurgeryRobotic Repair of Paraesophageal (Hiatal) Hernia with Mesh and LINX
8. Hiatal Hernia is the most common diaphragm herniaDiaphragm Hernia’s
9. Dr. Henry Bowditch reviewed all 88 published reports of diaphragmatic hernia 1610-1846All were postmortemThree cases noted what would be called a type 2 paraesophageal hernia.First Description of Paraesophageal Hernia
10. The Hiatal Hernia Diagnosis
11. Performed by : Angelo Soresi in 1919 has the first published description of elective surgery on the hiatus. Harrington at the Mayo Clinic published in 1928 a series of 27 pts. All early repair methods focused on recreating normal human anatomy with reduction of the GE junction into a natural position. Early Surgical Repairs
12. Barrett hypothesized that the shape of the G-E junction included a dome of the cardia above the G-E junction that was important to a flap valve function. Manometry was developed in 1956 and identified the LESEsophageal pH testing wasn’t developed till the 70’sHiatal Hernia and GERD Relationship
13. The Flap Valve of the GE Junction
14. Hill Grading System of the GE Junction
15. Endoscopic Views Hill Grades
16. GERD and/or Hiatal HerniaGERDHiatal HerniaWhat’s the roll of surgery for GERD?
17. 1956 Gastroplication by NissenThe advent of the Fundoplication
18. The Belsy Mark 4 (1967)
19. Hill’s Procedure (1967)
20. The variations of the Fundoplication
21. LINX Magnetic Sphincter Augmentation
22. Many sources/opinions to referenceIn general most guidelines agree to consider surgery for “symptomatic hiatal hernia”Inadequate control of symptoms on PPIMedication side effect or compliance problemsAdditional medical problems caused by GERD Barrett’s, Peptic Strictures, respiratory problems (aspiration)Gastric Volvulus, Extra-esophageal symptoms, lung compressionGERD patients who are well controlled on PPI but have a hernia and are expected to live more than 5 years. Surgery for Hiatal hernia https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629902/
23. Several randomized trials have been conductedMinimal surgical risks are notedRelief from PPI is variable from 90% to 40% off PPI at the conclusion of the studies 1-10 years.Surgery better than PPI? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2603580/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3629902/
24. GERD control is equivalent to fundoplicationBelching/Vomiting ability is preserved in >90% of patients (improved over fundoplications)LINX as an option for GERDhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC7000944/Insurance coverage can be a limitation
25. GERD and/or Hiatal HerniaGERDHiatal HerniaWhat’s the roll of surgery for Hiatal hernia?Probable Surgical Benefit
26. Recurrence is high for traditional repairsDepending on your reference of choice recurrence after typical hiatal hernia repair with fundoplication at 5 years is 10-50%. Many treatments effective for patients with GERD and no hiatal hernia have poor long term efficacy for patient with hiatal hernia. The Dark Side of Hiatal Hernia Repair
27. Divert into the history of the Inguinal Hernia Bassini - 1887Is surgical history repeating?
28. AuthorYearTechniqueEdoardo Bassini1887reconstructing the anatomy of the inguinal canalWilliam Steward Halsted1889subcutaneous position of the spermatic cordPaolo Postempski1890subcutaneous position of the spermatic cord and closure of external inguinal ringZdzisław Sławiński1916herniary sac left „in situ”, the neck of the sac used to close internal ringChester McVay1942Cooper’s ligament instead of inguinal (Poupart’s) ligament for the reconstructionEdward Earl Shouldice1953incision and reconstruction of the transverse fasciaVariations of the inguinal hernia repair
29. In 1983 Rand published that any non-mesh inguinal hernia repair had a 10% recurrence rate. Inguinal Hernia RecurrenceIf people have to be desperate before considering surgery, they present with advanced disease and complication rates are higher. When recurrence or complication rates are high (ie poor surgical quality), then people only choose to have surgery when they are desperate. The downward spiral of poor quality service and human suffering.
30. Evils of TensionMost surgeons at the time believed the failures were due to “tension” on the repair.
31. Published in 1989 with low recurrencesFollow up published in 1995 with 4000 pts showing 4 recurrencesThe “Tension Free” Inguinal Hernia Repair
32. Rives-Stoppa initially described a pre-peritoneal hernia repair with mesh using an open technique for giant and recurrent inguinal hernias in the 1966, performed for the first time in 1973. Laparoscopic modification of the method is now standard The Laparoscopic Inguinal Hernia Repair
33. Their techniques are reproducibleThe methods don’t require extreme surgical risks or extraordinary talent to completeThe methods provide for outpatient, low risk procedures with excellent risk profile for complication or recurrence. Why Lichtenstein and Reve-Stoppa?
34. The “Watchful Waiting” VA studyRandomized 720 men with asymptomatic inguinal hernia to surgery or waiting. Published in 2006 2-4 years F/UShowed 23% of patients crossed over to surgery due to increased painAfter 11 years of follow up, 68% of patients crossed over to surgery usually for symptoms of pain Low risk of bowel strangulationWhen should a hernia be repaired?
35. Inguinal hernias get slowly worse over time. The surgeries available now are outpatient, low risk, and highly effective with very low chance of hernia recurrence. Large hernias in older patients carry a higher risk of complication. Current State of the Art for Inguinal Hernia Why wait a long time to get your hernia repaired
36. Back to Hiatal Hernia again:Quality“Traditional” Open Inguinal Hernia Repair“Traditional” Hiatal Hernia Repair
37. Using retrospective data mining search methods, they found 89 pts who had Fluoro studies > 5 years apart. Only 20% of Type 1 HH were stableOnly 40% of larger HH were stableWhat happens to a Hiatal Hernia over time?https://pubmed.ncbi.nlm.nih.gov/32773629/
38. How to reduce recurrence rates for Hiatal Hernia Repair? Quality Improvement EffortsWhat has been done in the context of other hernia types to reduce recurrence rates? MeshRelaxing Incisions
39. Randomized controlled trials appear to demonstrate no long term benefit to use of dissolving mesh with hiatal hernia repair. Although early recurrence appears to be lower with use of absorbable mesh.Permanent mesh has been associated with erosion into the esophagus. The use of Mesh
40. Two studies indicate risk of hiatal hernia recurrence is low: 6.3% at 3 years, 4.3% at 1.5 yr Risk of post op complications are similar to published fundoplication data: dysphagia (5-15%), gas bloat 30%, persistent GERD (5-13%) with 90% of patient able to retain normal burping/vomiting ability. LINX in patients with Hiatal Hernia
41. Outpatient surgery
42. GERD and/or Hiatal HerniaGERDHiatal HerniaIs LINX better than traditional surgery?Probably notLikely Yes
43. Is LINX the Lichtenstein of Hiatal Hernia? ?
44. Probably YesSeveral studies with short and long term follow up have demonstrated lower rate of hiatal hernia recurrence than similar reports on traditional hiatal hernia repair recurrence rates.
45. LINX replaces the traditional Nissen Fundoplication component of a Hiatal Hernia Repair surgery. Only patient’s with normal swallow function can tolerate a LINX device (because I cannot adjust the magnetic attractions)How I Use LINX
46. A randomized trial for patients with hiatal hernia undergoing traditional surgery or LINX based repairs needs to be conducted. Most Insurance consider LINX for GERD to be investigational.Therefore at Boone LINX is provided by the hospital in the context of a paraesophageal hernia repair, because the reimbursement for that paraesophageal hernia repair is able to cover the cost of LINX and still turn a small profit. Additional Research is Needed:
47. Endoscopy Campus - Hiatus hernias and the Hill classification (endoscopy-campus.com)Historical aspects of the anatomy of the cardia with special reference to hiatus hernia. (nih.gov)https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1806549/?page=12The results of Hill's operation (oeso.org)FULL TEXT - A now rarely seen anti-reflux device: The Angelchik prosthesis - International Journal of Case Reports and Images (IJCRI) (ijcasereportsandimages.com)https://www.semanticscholar.org/paper/Diaphragmatic-relaxing-incisions-during-hernia-Greene-DeMeester/b57e959933f379bac648f492cbb25b86e647852bAntireflux Endoluminal Therapies: Past and Present (hindawi.com)References
48. Magnetic sphincter augmentation with hiatal hernia repair: long term outcomes - PubMed (nih.gov)Hiatal hernia recurrence following magnetic sphincter augmentation and posterior cruroplasty: intermediate-term outcomes - PubMed (nih.gov)Magnetic sphincter augmentation (MSA) in patients with hiatal hernia: clinical outcome and patterns of recurrence - PubMed (nih.gov)Efficacy of magnetic sphincter augmentation in patients with large hiatal hernias - PubMed (nih.gov)History of the Inguinal Hernia Repair | IntechOpenWatchful Waiting vs Repair of Inguinal Hernia in Minimally Symptomatic Men: A Randomized Clinical Trial | Surgery | JAMA | JAMA NetworkReferences