Paraconduit hernias after minimally invasive esophagectomy

Abstract

Central MessageParaconduit hernias after minimally invasive esophagectomy are managed with surgical repair. Multiple repair techniques have been described, although roughly 1/3 of repairs still result in recurrence.See Commentary on page XXX. Paraconduit hernias after minimally invasive esophagectomy are managed with surgical repair. Multiple repair techniques have been described, although roughly 1/3 of repairs still result in recurrence. See Commentary on page XXX. Esophageal cancer remains an aggressive malignancy, with surgery playing a critical role in treatment of resectable disease. Esophagectomy is a complex procedure, with the potential for the patient developing a paraconduit hernia months to years after surgery.1Gooszen J.A.H. Slaman A.E. van Dieren S. et al.Incidence and treatment of symptomatic diaphragmatic hernia after esophagectomy for cancer.Ann Thorac Surg. 2018; 106: 199-206Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Ganeshan D.M. Correa A.M. Bhosale P. et al.Diaphragmatic hernia after esophagectomy in 440 patients with long-term follow-up.Ann Thorac Surg. 2013; 96: 1138-1145Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 3Kent M.S. Luketich J.D. Tsai W. et al.Revisional surgery after esophagectomy: an analysis of 43 patients.Ann Thorac Surg. 2008; 86: 975-983Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar The likely etiology is recurrent gastric distention and decompression, leading to gradual enlargement of the hiatus.4Price T.N. Allen M.S. Nichols III, F.C. et al.Hiatal hernia after esophagectomy: analysis of 2,182 esophagectomies from a single institution.Ann Thorac Surg. 2011; 92: 2041-2045Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Although some patients with a paraconduit hernia may be asymptomatic, a majority of patients (56-83%) have symptoms such as abdominal pain, dyspnea, dysphagia, chest pain, nausea, or constipation.3Kent M.S. Luketich J.D. Tsai W. et al.Revisional surgery after esophagectomy: an analysis of 43 patients.Ann Thorac Surg. 2008; 86: 975-983Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar,5Oor J.E. Wiezer M.J. Hazebroek E.J. Hiatal hernia after open versus minimally invasive esophagectomy: a systematic review and meta-analysis.Ann Surg Oncol. 2016; 23: 2690-2698Crossref PubMed Scopus (58) Google Scholar Patients with these symptoms should undergo a computed tomography scan of the chest and abdomen to assess for possible paraconduit hernia. The most common hernia contents are colon (67-92%), small bowel (8-21%), pancreas (11%), and omentum.3Kent M.S. Luketich J.D. Tsai W. et al.Revisional surgery after esophagectomy: an analysis of 43 patients.Ann Thorac Surg. 2008; 86: 975-983Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar,6Lung K. Carroll P.A. Rogalla P. Yeung J. Darling G. Paraconduit hernia in the era of minimally invasive esophagectomy: underdiagnosed?.Ann Thorac Surg. 2021; 111: 1812-1819Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar In the series by Kent and colleagues,3Kent M.S. Luketich J.D. Tsai W. et al.Revisional surgery after esophagectomy: an analysis of 43 patients.Ann Thorac Surg. 2008; 86: 975-983Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar 87% of paraconduit hernias were located to the left of the gastric conduit, with abdominal contents herniating into the left pleural space. The other 13% of patients had the hernia posterior to the conduit, with abdominal contents in the right chest.3Kent M.S. Luketich J.D. Tsai W. et al.Revisional surgery after esophagectomy: an analysis of 43 patients.Ann Thorac Surg. 2008; 86: 975-983Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar The hernia may also compress the distal conduit, leading to outflow obstruction (Figure 1). Interestingly, as the technique of esophagectomy has changed from open resection to minimally invasive, the incidence of paraco