D. Shehata1, J. Batchelder1, I. Doulamis1, E. Lopez1, S. Moffatt-Bruce1, E. Servais1, A. Watkins1, C. Stock1 1Lahey Hospital and Medical Center, Division Of Thoracic And Cardiovascular Surgery, Burlington, MASSACHUSETTS, USA
Introduction: Recent studies have reported an increased incidence of paraconduit hernia following the advent of minimally invasive esophagectomy (MIE), with a high recurrence rate after repair remaining a significant concern (1). This study aims to review the incidence, risk factors, and recurrence of paraconduit hernia following robotic-assisted esophagectomy.
Methods: We conducted a retrospective single-center analysis on consecutive patients who underwent robotic-assisted esophagectomy from 2018 to 2023. We collected and analyzed data on the incidence of paraconduit hernia (PCH), associated risk factors, and clinical outcomes. All of our PCH repairs were performed using a robotic-assisted approach; patients who required an unplanned conversion to open surgery were excluded. Our technique involved reduction of the hernia followed by primary closure of the diaphragm hiatus without mesh. Additional sutures are placed between the gastric conduit and diaphragm hiatus 180 degrees of the anterior aspect of the conduit.
Results: During the study period, 77 patients underwent robotic-assisted esophagectomy, of which 8 patients (10.3%) developed a paraconduit hernia at a median of 365 days (IQR 272.5-730). Three were detected from CT reports and 5 by individual image review. Patients in the PCH group did not differ in baseline characteristics. They were predominantly males (88.8%) with an ASA class of III. Of the 8, 4 (44.4%) had a pre-esophagectomy hiatal hernia. Hernias were symptomatic in 3 patients (33.3%), while the remaining 5 were detected radiographically. Repair was performed in 2 of the 3 symptomatic patients (66.6%) and none of the asymptomatic patients needed a repair. None of the patients who underwent repair experienced a recurrence during the median follow-up period of 2.5 years. No factors were identified to be associated with paraconduit hernia development on univariable and multivariable analyses. No patient with PCH experienced an acute complication of the hernia that required emergency intervention.
Conclusion: While there is concern about the increased incidence of paraconduit hernia with the adoption of MIE, only a small fraction require repair. Many cases can be monitored without long-term complications, making watchful waiting an acceptable approach.
1-Chang SH, Molena D. Paraconduit hernias after minimally invasive esophagectomy. JTCVS Tech. 2024;24:213-216. Published 2024 Feb 10.