Incidence of diaphragmatic hernias following minimally invasive versus open transthoracic Ivor Lewis McKeown esophagectomy

To compare the incidence of post-operative hiatal herniation after open and minimally invasive Ivor Lewis McKeown esophagectomy for malignant disease. All patients undergoing esophageal resection were entered into a prospectively maintained database. After Institutional Review Board approval, the database was queried to identify patients who underwent minimally invasive (MIE) and open transthoracic (TTE) Ivor Lewis McKeown esophagectomy (transthoracic three-hole) with gastric pull-up for malignant disease. The cohorts were compared for the incidence of hiatal hernia on routine CT scan for cancer surveillance. Data up to 24 months post-operatively was included. Patients undergoing trans-hiatal or hybrid procedures as well as intra-thoracic anastomosis were excluded as were patients in whom jejunum or colon was used for reconstruction. Between 2003 and 2009, 19 MIEs and 20 open TTEs met the inclusion criteria. There was no significant difference in age, co-morbidity, pathology or perioperative morbidity and mortality between the two groups. During routine follow-up, para-gastric hiatal hernia was noted on CT scan in 5(26%) patients following MIE at a mean of 13.8 months postoperatively, with incidence ranging from 3 to 20 months postoperatively (19, 20, 18, 3, and 9 months, respectively). Hernia contents in these patients were omentum in one case and colon in the other four cases. None of the patients undergoing TTE were noted to have herniation (P = 0.01). All hernias were asymptomatic; three were repaired electively. There was a significantly higher incidence of para-gastric hiatal hernia after Ivor Lewis McKeown minimally invasive esophagectomy compared to similar open procedures. Additional precautions to prevent para-gastric hernia should be taken during laparoscopic resection.