Laparoscopic Paraesophageal/Hiatal Hernia Repair

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Author: P. Marco Fisichella
Published:
Specialties: General Surgery
Schools: Brigham and Women's Hospital, University of Chicago
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Basic Info

Contributor: Ciro Andolfi (University of Chicago), Marco G. Patti (University of Chicago)

We describe our preoperative work-up and the surgical technique of Laparoscopic paraesophageal/hiatal hernia repair.

DOI: http://dx.doi.org/10.17797/56by9lqzf5

Editor Recruited By: Dr. Jeffrey Matthews

Advanced

Procedure

LAPAROSCOPIC PARAESOPHAGEAL HERNIA REPAIR
A 66-year-old woman seeks medical attention for intermittent epigastric pain. After dinner she experienced an excruciating epigastric pain that moved to her chest, associated with nausea. A Barium swallow evaluation of the upper GI and a CT scan were performed, demonstrating an organ-axial volvulus with approximately 50% of the stomach within the chest.

Indications

severe symptoms, gastric volvulus

Contraindications

There are no contraindications to a laparoscopic approach as the patient is otherwise healthy.

Instrumentation

Setup

The patient lies supine on the operating table in low lithotomy position with the lower extremities extended on stirrups with knees flexed 20-30°; a bean bag is inflated to avoid sliding of the patient; an orogastric tube is placed to decompress the stomach; the surgeon stands between the patient's legs, while first and second assistant stand on the right and left side respectively. A five trocar technique is used for this procedure; a first trocar is placed 14 cm inferior to the xiphoid process, in the midline, for a 30° scope; a second trocar is placed in the left midclavicular line, at the same level with the first trocar, to introduce a Babcock clamp; a third trocar is placed in the right midclavicular line, at the same level of the other two trocars, and it is used for the insertion of a retractor to lift the liver; a fourth and a fifth trocar are placed under the right and left costal margins and they are used for the dissecting and suturing instruments.

Preoperative Workup

Essential investigations are barium swallow and CT scan.

Anatomy and Landmarks

Excluding placement and removal of trocars, we can consider seven major steps for this surgery.
1.Reduction of the hernia.
2.Section of the short gastric vessels.
3.Section of the phrenoesophageal membrane.
4.Hernia sac dissection and resection.
5.Dissection of the posterior mediastinum and esophageal mobilization.
6.Crural repair.
7.Fundoplication.
Although a total fundoplication is the procedure of choice, a partial posterior or anterior fundoplication may be considered during emergencies, which do not allow performing an esophageal manometry.

Advantages/Disadvantages

In case of proper pre-operative assessment, with a normal esophageal peristalsis demonstrated with a manometry, a total fundoplication should be considered.
The patient starts a soft diet the morning of the first post-operative day; it's important to avoid meat, bread and carbonate beverages for 2 weeks; the patient was discharged within 23h after the operation. A barium swallow is usually obtained between 6 and 12 months post-operatively to assess for any recurrence

Complications/Risks

Intra-operative complications are pneumothorax, esophageal or gastric perforation, splenic injury, and vagal nerve injury. Post-operative complications are dysphagia and persistent or recurrent reflux and symptoms.

Disclosure of Conflicts

Acknowledgements

None

References

Fisichella PM, Allaix ME, Morino M, Patti MG â Esophageal Diseases. Evaluation and Treatment. Springer Edition.
Fisichella PM. A synopsis of techniques for paraesophageal hernia repair: different approaches to current controversies. Surg Laparosc Endosc Percut Tech. 2013;23(5):423-4.
Dallemagne B, Kohnen L, Perretta S, et al. Laparoscopic repair of paraesophageal hernia. Long-term follow-up reveals good clinical outcome despite high radiological recurrence rate. Ann Surg. 2011;253:291-6.
Weber C, Davis CS, Shankaran V, Fisichella PM. Hiatal hernias: a review of the pathophysiologic theories and implication for research. Surg Endosc. 2011;25(10):3149-53.
Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of paraesophageal hiatal hernias. J Am Coll Surg. 1998;186:428-32.

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