A narrative review of paraconduit hernia after esophagectomy: where are we now?

Objective: To discuss potential mechanisms and risk factors for the rise in incidence with MIE techniques as well as examine recent data supporting indications and techniques for repair of paraesophageal hernias. Background: Esophagectomy is the standard of care for surgically resectable esophageal cancers. Recent advances in minimally invasive esophagectomy (MIE) and hybrid techniques over the past several years have provided less morbid, oncologic equivalent strategies as compared with traditional open abdominal or transthoracic approaches. While this has generally led to improved patient outcomes, there has been a commensurate rise in the incidence of paraesophageal hernias, a known complication that is likely secondary to iatrogenic widening and instrumentation of the hiatus. Currently, indications and timing for repair of paraconduit hernias remain disputed. Methods: We performed a literature review of reports describing the incidence rate, operative techniques, and recent advances in the diagnosis and management of paraconduit hernias over the past decade. Conclusions: Incidence rates appear to be highest for the MIE transthoracic Ivor Lewis approach, although the increasingly utilized transhiatal robot-assisted esophagectomy may be associated with similar rates of hernia occurrence. Surveillance is a reasonable option for patients without symptoms, especially those with limited life expectancy given the nontrivial morbidity and recurrence rates after repair; however, laparoscopic surgical repair should be considered for symptomatic patients given the risk of rapid progression and subsequent perforation. Future work should examine surgical techniques for prevention of post-esophagectomy hernia.