The preoperative physical status of the patient dictates anesthetic management of patients with paraesophageal hernia. Patients suffering from this disease often can experience chronic aspiration leading to a poor preoperative respiratory status. Consideration of co-morbid conditions is equally important, as the diagnosis is frequently made in older debilitated patients and preoperative evaluation is essential for assessing the operative risk in the individual patient. It is essential for the anesthesia team to have a detailed understanding of the surgical procedure in terms of approach, the extent of the operation, and associated complications. Special emphasis should be placed on the assessment of cardiopulmonary function, because intraabdominal CO2 insufflation may be poorly tolerated in patients with severe cardiopulmonary compromise. Preoperative cardiac and pulmonary morbidity will determine the extent of preoperative cardiac testing as well as the need for pulmonary function testing (PFT) especially in those patients with restrictive lung disease secondary to recurrent aspiration pneumonia.

Patients with PEH are at an increased risk for aspiration during induction of anesthesia. For that reason they are advised to ingest only clear liquids 2 or 3 days before surgery, to decrease the risk of aspiration. In older patients with several comorbid conditions, a Foley catheter is placed and usually removed after the case. Premedication with a prophylactic anti-aspiration is highly recommended. The patient is placed in the supine position before the induction of general endotracheal anesthesia. In order to minimize the aspiration risk during the induction of anesthesia, the airway can be secured either after a rapid sequence induction with cricoid pressure, or awake with the aid of a fiberoptic bronchoscope. With the identification of risk factors, patients undergoing esophageal surgery could be stratified. Standard intraoperative monitoring will suffice for American Society of Anesthesiologists (ASA) physical status class I and II patients. More invasive monitoring may be required in patients with underlying cardiopulmonary pathology [16]. Adequate attention should be paid to the hemodynamic changes resulting from the combined effects of pneumoperitoneum and placing the patient in a reverse Trendelenburg position. Venous stasis in the lower extremities during the head-up position may be aggravated in the lithotomy position. Consequently, prophylactic measures to minimize the risk for deep venous thrombosis and pulmonary embolism must be considered such as the use pneumatic compression stocking for mechanical deep venous thrombosis (DVT) prophylaxis, and consideration should be given to chemical prophylaxis as well (e.g. low molecular weight heparin).

Due to the extensive mediastinal dissection, subcutaneous emphysema is frequently observed. Subcutaneous crepitus may be palpated in the face, neck, shoulders, and upper chest. Often times this issue is discovered after the completion of the case when the surgical drapes are taken down. This issue is infrequently of clinical significance and resolves without therapy [18]. However, if discovered early during the case the recommendation is to lower the CO2 insufflation pressure.

Another relatively common postoperative complaint from patients is left shoulder pain. This is the result of irritation of the left diaphragm and is self-limited.

Nausea and vomiting after laparoscopic foregut surgery is considered a major setback, since it is not only a reason for patient distress but can also predispose the patient to anatomical failure. It has been reported that up to 60% of patients suffer from postoperative nausea and as many as 5% experience vomiting soon after a fundoplication [19]. A number of pre and intraoperative anesthesia considerations should be taken into account to enhance postoperative patient recovery such as different ventilation strategies, minimizing intraoperative fluids, multimodal analgesia, limiting use of long acting opioids as well as routine antiemetic strategies like prophylactic treatment with intravenous antiemetics are always recommended. Patients with intractable postoperative vomiting should be carefully assessed before they are discharged in order to assure the integrity of their recent repair [20]. Gastric distension should be recognized early as it can be potentially dangerous in the immediate postoperative phase, and can be treated successfully by the placement of a nasogastric tube.

An increased incidence of flatulence occurs in approximately in half of patients undergoing hiatal hernia repair [21]. In addition, patients often complain of bloating and reduced ability to belch. The occurrence of gas bloating syndrome is associated with competent wrap, aerophagia and in some patients it is possibly associated with delayed gastric emptying due to unrecognized vagal nerve injury. Nevertheless, in the majority of patients these symptoms are transient, but if persistent it will decrease patient satisfaction and could result in failure of the procedure [22]. Patients with these adverse events should initially be treated conservatively with dietary counseling (avoid gas producing foods) and the use of anti-gas medications (simethicone) as needed.

New onset of diarrhea is a common side effect after hiatal hernia repair, identified in almost 20% of patients [23]. The cause of the diarrhea is unknown; however, it is important to document the presence of gastrointestinal symptoms before surgery since is expected that these patients will experience the same symptoms after surgery. The suggested mechanisms include (1) rapid gastric emptying, and (2) vagal nerve injury with subsequent bacterial overgrowth. The diarrhea tends to be low volume and postprandial. Antimotility agents including codeine, antibiotics for small bowel overgrowth, and cholestyramine may ease the diarrhea, but the management is empirical.

A significant number of patients experience dysphagia mainly for solids after paraesophageal hernia repair. This is primarily due to the modified anatomy and postoperative inflammatory changes. This dysphagia is transient in more than 90% of patients and resolves within the first 6–8 weeks of the surgery. In the early postoperative period patients usually receive dietary counseling and are recommended a special diet with slow progression from liquids to solid food paying special attention to adequate caloric intake. One should be vigilant about patients that experience severe dysphagia for liquids in the early postoperative period. Further workup may be warranted to rule out any anatomic failure. Patients that present with persistent dysphagia beyond 3 months of surgery need further investigation in order to determine the etiology of the dysphagia. This will be discussed later in this chapter.

Pleural injury or tear is not an uncommon complication due to the close relationship between the hernia sac and the mediastinal pleura. Factors predisposing patients to this complication are periesophagitis, the presence of large hernias and obesity. Although intraoperative pneumothorax may develop after the opening of the mediastinal pleura its consequences for the patient are negligible since CO2 is quickly reabsorbed and the lung is rarely involved. Rates of pneumothorax during laparoscopic antireflux surgery in most series range from 0% to 1.5% but may be as high as 10% especially in repairing paraesophageal hernias [24]. It is extremely important for the operating surgeon to communicate with the anesthesiologist if pleural injury ensues. Adequate monitoring of end-tidal carbon dioxide levels (EtCO2) and airway pressures will facilitate early diagnosis. Positive end-expiratory pressure (PEEP) application is an effective way of managing pneumothorax secondary to the passage of gas into the pleural space. In our experience, intraoperative closure of the pleural defect with locking clips as well as decreasing the intraabdominal pressure have helped stop CO2 diffusion into the pleural cavity (Fig. 7.1). Because the CO2 is highly diffusible, sealing the pleural injury has not resulted in tension pneumothorax.

Substantial bleeding during paraesophageal hernia repair is uncommon mainly due to new developments in energy devices and increased surgeon’s experience. The most commonly reported causes for bleeding come from ineffective division of the short gastric vessels, splenic injury, or liver laceration. Less frequently, bleeding results from injury to the left gastric artery, aorta or inferior vena cava.

The so-called “left crus approach” entails early division of the short gastric vessels, which provides the advantage to identify the left crus of the diaphragm and avoid the vascular structures from the gastroepiplioc omentum. Excessive traction from the fundus to reduce the herniated stomach and inappropriate use of energy devices are amongst the primary causes of bleeding that can result in splenic capsular tear or short gastric vessels disruption. This maneuver is especially more difficult if the uppermost short gastric vessels are exceedingly short. In this case one alternative is to use to the assistant surgeon to retract the body and fundus of the stomach medially to further separate the stomach from the spleen to create a plane posteriorly for safe transection. Of course this dissection is more tedious in obese patients. If bleeding were to occur, individualization of the bleeding vessel and control with an atraumatic grasper are the first steps to stop the hemorrhage. Direct application of ultrasonic or bipolar energy generally is effective; however, if the stump of the vessel is too short suture ligation can be considered.

The incidence of splenectomy has decreased considerably with the implementation of laparoscopic surgery (0.06%) compared to open surgery (around 5%) [22, 25]. This is likely due to more precise and delicate maneuvers along with the enhanced energy devices (ultrasonic shears, bipolar), and visualization of the operative field. In addition, the adjunctive use of topical hemostatic agents can control intraoperative bleeding. Today there is a broad range of products such as, Bovine gelatin and pooled human thrombin (FLOSEAL, Baxter Corporation, Deerfield, Il), Pooled human plasma (EVICE), Oxidized regenerated cellulose (SURGICEL) (ETHICON Johnson & Johnson, Inc., Somerville, NJ) etc. However, is not advised to use these agents as the first line of response.

The anterior and posterior vagus nerves should be identified and preserved during the esophageal mobilization and dissection of the hernia sac. If while attempting to resect the hernia there is concern regarding the location of the nerves then it is prudent to preserve a portion of the sac. The exact incidence of accidental vagus nerve injury during antireflux surgery is not well known, but is thought to be approximately 2%. The risk is clearly higher with paraesophageal hernias. This can result in significantly delayed gastric emptying and is associated with diarrhea bloating and early satiety. These patients should undergo a gastric emptying study to confirm their gastroparesis. If post-surgical gastroparesis is diagnosed, and symptoms relapse despite adequate medical treatment a pyloroplasty may be indicated [26].

Injury to the esophagus and stomach are undoubtedly the most serious complications during paraesophageal hernia repair with potentially life-threatening consequences. However, the information provided in the literature is rather scarce. The incidence of these dreaded complications range from 0% to 4% [24]. Commonly, such injuries occur by very defined mechanisms, namely excessive traction of the stomach or the hernia sac, inadequate dissection of the esophagus or placement of the esophageal bougie. Understanding of these mechanisms as well as the morbid anatomy is fundamental to prevent these serious complications. It is essential for the operating surgeon to recognize the intrinsic challenges of paraesophageal hernias and the increased complications associated with their repair are knowingly higher than those seen in laparoscopic fundoplication for reflux disease [14]. In addition, the surgeons’ level of experience is an important factor to contemplate [27]. The majority of perforations are recognized and repaired intraoperatively with no major consequences for the patient [28]. Still, the greatest threat to the patient are unrecognized perforations that could lead to mortality.

Most gastric injuries are minor serosal tears usually caused by forceful traction from the fundus to reduce the herniated stomach. Intra-thoracic gastric tissues tend to be congested and friable and therefore can lead to increased incidence of perforations if inadequately handled. Gastric perforation can also happen while performing the posterior mobilization of the gastric fundus. Perforation of the stomach should be identified before constructing the fundoplication. Seromuscular injuries should be reinforced with Lembert sutures. Full thickness perforations can be repaired with interrupted absorbable/non-absorbable, full thickness stitches or linear stapler.

Esophageal injury is a known complication of laparoscopic antireflux surgery. Authors have reported a higher incidence of this complication with paraesophageal hernia repair [14]. Strategies to prevent esophageal perforations are essential and can be summarized as: (1) optimization of exposure, (2) recognition of the anatomical landmarks, (3) avoidance of excessive traction of the stomach/hernia sac, (4) avoidance of excessive use of energy, (5) experienced anesthesiologist passing the bougie, (6) correction of the gastroesophageal junction angulation, (7) avoidance of esophageal dissection with intraesophageal bougies or nasogastric tubes, and (8) identifying and repairing the perforation intraoperatively (leak test with upper endoscopy and air insufflation; or with methylene blue). Other procedural steps that carry an added risk of esophageal or gastric injury are: the resection of the hernia sac, generally due to either excessive traction or thermal injury and the creation of the fundoplication with the bougie in place. For that reason, we bring the bougie into the stomach after the first stitch of the fundoplication has been placed (Fig. 7.2).

A recognized injury to the esophagus should be immediately repaired. This could be undertaken laparoscopically since the exposure of the area is better. However, the decision to convert to open should be made based upon the location of the perforation and the surgeon’s intracorporeal suturing skills. The perforation should be repaired with a single layer full thickness interrupted absorbable sutures. The fundoplication can be used to buttress the repair. A postoperative swallow study should be obtained before starting the diet.

Esophageal perforation remains a major diagnostic and therapeutic challenge. Despite all the strategies to prevent a perforation, it has been reported to be as high as 1.5–6.5% after paraesophageal hernia repair [29]. The clinical presentation is variable; whereas some patients may present with obvious mediastinitis/peritonitis and sepsis that can lead to multi-organ failure, others present with subtle signs and symptoms that can lead to treatment delays. For that reason, it is important to have a high index of suspicion since a delay in diagnosis greater than 24 h post-perforation doubles the risk of mortality [30]. If stable, the patients should be evaluated with a water-soluble contrast study as well as a CT scan to evaluate for fluid collections. After the confirmation of the diagnosis, stabilization of the patient (NPO, IV fluids, broad spectrum antibiotics) the surgeon must decide whether to opt for operative or conservative management. Historically, esophageal perforation has been considered a surgical emergency. Nonetheless, changes in surgical practice have occurred in recent years, expanding the management options. The stability of the patient is an important factor at the time of deciding for treatment. In stable patients with minimal extra luminal contamination, conservative treatment is an acceptable alternative [31]. On the other hand; patients with extensive mediastinal/peritoneal contamination require emergency surgery. At the time of the exploration primary repair can be attempted. Often times, primary repair cannot be accomplished because of the delayed presentation of the perforation and the widespread contamination [32]. If primary repair is not feasible, either percutaneous or surgical drainage should be attempted in conjunction with endoscopic clips and stenting [33]. Coated stents have demonstrated to be useful for the treatment of leaks. Stents are left in place for an average of 6–8 weeks. PEG tube or jejunostomy feeding can be implemented while progressing to oral feeding with the stent in place. We perform our own stent placement in the operating room under endoscopic guidance (Fig. 7.3).