Laparoscopic anterior hemifundoplication and hiatoplasty for the treatment of upside-down stomach: mid- and long-term results after 40 patients.

Background: Treatment of type 4 hiatal hernia using a minimally invasive approach is challenging and requires good familiarity with this technique.

Methods: From October 1992 to August 2010, 40 patients with a median age of 68 years underwent laparoscopic anterior hemifundoplication surgery for upside-down stomach and were included in our prospective study. The median symptoms duration was 5 years. The leading clinical symptoms were postprandial, epigastric, or retrosternal pain (80%), heartburn (78%), regurgitation (80%), dysphagia (53%), and anemia (48%). Preoperative evaluation included blood test, chest X-ray, upper endoscopy, and barium swallow. In some patients an esophageal 24-h pH study and esophageal manometry were performed. The median follow-up was 46 months using a standardized questionnaire, including Smiley score, modified Visick score, gastrointestinal quality-of-life index (GQLI), and specific reflux symptoms score.

Results: Surgery was finished laparoscopically in 39 patients (97%). One patient had to be converted to an open procedure because of severe adhesions. Mesh hiatoplasty had to be performed in one patient due to a large hiatal defect. Median operative time was 160 min (range=90-275) and median blood loss was 5 ml (range=0-300). Seven patients (18%) presented with acute symptoms. Intraoperative technical complications occurred in four patients (10%) and nontechnical complications in two cases (5%). Median postoperative hospital stay was 5 days (range=2-17). Postoperative complications occurred in two patients (5%): one pleural effusion and one surgical emphysema. There was no mortality or symptomatic recurrence. All scores showed significant improvement and patient satisfaction.

Conclusion: Laparoscopic treatment of type 4 hiatal hernia is safe. With respect to the quality of life, anterior hemifundoplication is highly effective.