3 and 5 Large openings between the abdomen and thorax are well tolerated during laparoscopic surgery, and in the absence of an injury to lung parenchyma no chest tube or KU-60019 pleural drainage catheter was placed

at the conclusion of the surgery. Symptomatic postoperative pleural effusions were managed with an ultrasound or CT-guided pigtail drain. The most commonly encountered form of tension was related to a short esophagus. The existence and importance of esophageal shortening continues to be debated, but if present and unaddressed, it can place the repair under tension. Our practice was to add a Collis gastroplasty when there was less than 3 cm of intra-abdominal esophagus after mediastinal esophageal mobilization. We have

found the wedge-fundectomy technique to be simple to perform and associated with few complications.7 In this series, there was 1 patient with an esophageal leak related to the Collis staple line. This patient had chronic leukemia and poor healing, and the leak was treated with endoscopic stent placement. After a Collis gastroplasty, we routinely performed upper endoscopy at 3 months, and if esophagitis related to the gastroplasty was found, the patient was placed on acid suppression medication. We have not found the addition of a Collis gastroplasty to be associated with significant AZD2281 mouse dysphagia.7 All patients had primary crural closure despite, in some cases, a massive hiatal opening. The crural closure was reinforced with an AlloMax biologic mesh graft placed posterior to the esophagus. Rarely, if sutures were placed anterior to the esophagus to prevent a “speed bump” deformity, the Allomax graft was placed completely around the esophagus. It has been our practice to routinely use mesh to reinforce the primary crural closure in patients with a large (≥5 cm) sliding

or paraesophageal hernia, those with thin or atrophic crural pillars, and in all patients undergoing a reoperation for recurrent hiatal hernia. Our rationale is that the crura lack fascia and are often thin in patients with a sizeable hiatal hernia. In addition, the diaphragm moves 15,000 to 20,000 Terminal deoxynucleotidyl transferase times a day with respiration and contracts vigorously with coughing, sneezing, or vomiting. Finally, there is a natural pressure gradient between the chest and abdomen that encourages migration of intra-abdominal organs into the chest should a separation develop in the crural reapproximation. The use of mesh at the hiatus remains controversial. Permanent synthetic mesh has been reported to reduce the frequency of hernia recurrence, but at the risk of mesh infection or erosion.10 A variety of techniques have been reported for placement of the mesh. Some have placed it posterior to the esophagus; others create a “key-hole” for the esophagus within the mesh and reinforce the entire hiatus.