Laparoscopic Repair of Acute Post-Esophagectomy Diaphragmatic Herniation Following Minimal Access Esophagectomy

This study’s objective was to assess the presentation, incidence, operative approach, and outcomes of acute symptomatic post-esophagectomy diaphragmatic hernia (PEDH), following minimal access esophagectomy (MAE) for esophageal and gastro-esophageal junctional cancer. Between January 2010 and December 2020, all consecutive patients undergoing esophagectomy were retrospectively analyzed. Acute symptomatic PEDH occurred in 4 patients out of 680 consecutive patients undergoing esophagectomy (0.58%) and 636 MAE (0.63%). All patients were men, with a median age of 56.5 years, and underwent minimal access transhiatal resection. The presentation was varied; 2 had restlessness, agitation, and tachycardia; one acute respiratory distress; and the last was asymptomatic but had reduced air entry over left hemithorax with unexplained hypoxia. All had transverse colon herniation into the left hemithorax. Herniated viscera were reduced with closure of hiatal defect, 3 underwent laparoscopic repair, and one needed laparotomy. Meshplasty or bowel resection was not required. The median hospital stay was 9 days with no perioperative mortality. The major complications (Clavien-Dindo grade ≥ IIIa) occurred in 2 patients. One patient was lost to follow-up, 2 died of disease after a year and 15 months post-procedure, and one is doing well at 10 months without any relapse of hernia. Acute symptomatic PEDH is a rare complication after transhiatal esophagectomy and mainly occurs in the left hemithorax. The incidence appears to be less than 1% after MAE. Laparoscopic repair is feasible in most cases. We recommend routine assessment of hiatus and tightening of hiatus to snuggly accommodate the gastric conduit.