Laparoscopic Repair of Hiatal Hernia
Introduction
The esophageal hiatus is an elliptical opening in the diaphragmatic muscular portion. The crura of diaphragm originate from the anterior surface of the first four lumbar vertebrae on the right and L2–L3 on the left to insert anteriorly into the transverse ligament of the central portion of the diaphragm. Hiatal hernia is an opening in the diaphragm through which stomach or omentum is forced into the chest cavity. A hiatus hernia can exist without any symptoms.
Hiatus hernia
Type I or Sliding Hernia
Gastroesophageal (GE) junction migrates above the esophageal hiatus. It is the most common type of hiatus hernia (80%). This results in loss of the cardiac angle of His and commonly incompetence of the cardioesophageal junction. Symptoms and complications of this type of hernia are those which are the consequence of gastroesophageal reflux and reflux esophagitis (Chronic blood loss, stricture, Barrett’s epithelium, etc.).
Type II or Paraesophageal
True paraesophageal hernia characterized by normally positioned GE junction and an intrathoracically migrated stomach. The fundus of the stomach rotates in front of the esophagus and herniates through the hiatus into the mediastinum. As the cardioesophageal junction remains in situ within the abdomen cardiac incompetence and reflux are not usually encountered. These herniae account for 8 to 10 percent of cases and are found predominantly in elderly patients. This type of hernia is prone to incarceration and strangulation with infarction and perforation of the stomach.
Type III or Mixed Hernia
Mixed hernia with sliding and a paraesophageal component. This resembles a large paraesophageal hernia but gastroesophageal junction is also herniated above the diaphragm. The mixed hernia has features and complications of both types I and II hernia. It is found in 10 percent of patients.
There are rare instances of post-traumatic herniation of the stomach through the hiatus and these must be differentiated from the traumatic rupture of diaphragm. In the majority of cases, the development of hiatus hernia is spontaneous. Gallstone and colonic diverticular disease are commonly present in patients with a hiatus hernia (Saint’s triad).
Symptoms of Type II Hiatus Hernia
• Typical heartburn (47%)
• Dysphagia (35%)
• Epigastric pain (26%)
• Vomiting (23%)
• Anemia (21%)
• Barrett's epithelium (13%)
• Aspiration (7%).
Symptomatic gastroesophageal reflux disease (GERD) is frequently associated with a finding a sliding hernia. A number of procedures like Nissen’s fundoplication and its modification (the Toupet procedure), Hill’s procedure, and Belsey transthoracic repair have been described. Nissen’s fundoplication is, however, the simplest and most effective. Success has been achieved in performing the laparoscopic Nissen’s fundoplication, Hill’s repair, and Toupet procedure as well as thoracoscopic Belsey Mark IV. Laparoscopic Nissen’s fundoplication shows the most progress and has the potential of becoming a gold standard. It offers the opportunity for correction of the underlying anatomical and functional defect associated with GERD with lessened discomfort and hospitalization.
The indications are:
• Severe heartburn
• Refractory to medical therapy-symptoms present twelve weeks after therapy
• Noncompliance with therapy
• Development of complications like aspiration
• A type of hiatal hernia where the stomach is at risk of getting stuck in the chest or twisting on itself (paraesophageal hernia)
• Bleeding
• Barrett’s mucosa
• Stricture.
Relative contraindications include:
• Previous Hiatal or upper abdominal surgery
• Morbid obesity with left hepatomegaly
• Shortened esophagus
• Aperistalsis of the esophagus (achalasia, scleroderma, end-stage GERD).
Appropriate preoperative evaluation of esophagogastric junction is essential prior to perform laparoscopic fundoplication. Failure of surgery to control symptoms occurs in up to 10 percent of cases. It is a reflection that antireflux surgery has been inadvertently utilized for unrecognized cardiac, hepatobiliary, esophageal, or gastric etiologies.
Preoperative Evaluation
Preoperative investigation can be divided into mandatory and selective tests.
Mandatory
• Endoscopy UGI with/without biopsy
• Esophageal manometry.
Selective
• Barium swallow
• 24 hours pH monitoring
• Gastric studies.
At least 3 cm of the esophagus must be mobilized into the abdomen to ensure adequate intra-abdominal length for fixation. If a hiatal hernia is present, the crura are approximated with 2 to 3 sutures of No. Zero non- absorbable suture. The short gastric vessels are routinely divided along the upper one-third of the stomach using the harmonic scalpel. A 2 cm wrap is adequate with the incorporation of the esophagus into the wrap to prevent slippage. Postoperatively a chest X-ray is obtained in the recovery room to exclude a pneumothorax. Patients are kept on clear liquids on the day of surgery and soft diet the following day. The average length of stay is 2 days. Intraoperative complications may include injury to visceral organs, bleeding, pneumothorax, and vagal injury. Postoperative complications include wrap slippage.
Port Position
The patient is positioned supine on the operating table, and the surgeon works from the right side with the assistant on the left. Four 5 mm and one 10 mm laparoscopic ports are placed in the upper abdomen.
Port position in hiatus hernia
Operative Procedure of Giant Paraesophaegal Hernia
After exposing the hiatus, the herniated stomach is reduced into the abdomen using atraumatic graspers in a “hand-over-hand” fashion. Dissection is started for exposing the right and left crura of the diaphragm and mobilizing the esophagus. Sling is applied to retract the esophagus and facilitate mobilization of the esophagus posteriorly. Once the dissection is the complete appropriate size of the mesh should be taken and suture from below the esophagus to repair the defect.
Recommendation to Avoid Complication
• Ports should be placed high on the abdomen since much of the stomach will be up in the mediastinum.
• Compression stockings and subcutaneous heparin should be used to prevent deep venous thrombosis.
• Intra-abdominal pressures less than 15 mm Hg should be used.
• Prefer the bipolar for mobilization of the anterior gastroesophageal fat pad.
• It is important to remove the hernia sac from the mediastinum while avoiding entry into the pleural spaces.
• Stomach should be handled gently with graspers–the chronically herniated stomach perforates relatively easily.
• At the end of surgery perforations or leaks during dissection should be watched carefully.
Introduction
The esophageal hiatus is an elliptical opening in the diaphragmatic muscular portion. The crura of diaphragm originate from the anterior surface of the first four lumbar vertebrae on the right and L2–L3 on the left to insert anteriorly into the transverse ligament of the central portion of the diaphragm. Hiatal hernia is an opening in the diaphragm through which stomach or omentum is forced into the chest cavity. A hiatus hernia can exist without any symptoms.
Hiatus hernia
Type I or Sliding Hernia
Gastroesophageal (GE) junction migrates above the esophageal hiatus. It is the most common type of hiatus hernia (80%). This results in loss of the cardiac angle of His and commonly incompetence of the cardioesophageal junction. Symptoms and complications of this type of hernia are those which are the consequence of gastroesophageal reflux and reflux esophagitis (Chronic blood loss, stricture, Barrett’s epithelium, etc.).
Type II or Paraesophageal
True paraesophageal hernia characterized by normally positioned GE junction and an intrathoracically migrated stomach. The fundus of the stomach rotates in front of the esophagus and herniates through the hiatus into the mediastinum. As the cardioesophageal junction remains in situ within the abdomen cardiac incompetence and reflux are not usually encountered. These herniae account for 8 to 10 percent of cases and are found predominantly in elderly patients. This type of hernia is prone to incarceration and strangulation with infarction and perforation of the stomach.
Type III or Mixed Hernia
Mixed hernia with sliding and a paraesophageal component. This resembles a large paraesophageal hernia but gastroesophageal junction is also herniated above the diaphragm. The mixed hernia has features and complications of both types I and II hernia. It is found in 10 percent of patients.
There are rare instances of post-traumatic herniation of the stomach through the hiatus and these must be differentiated from the traumatic rupture of diaphragm. In the majority of cases, the development of hiatus hernia is spontaneous. Gallstone and colonic diverticular disease are commonly present in patients with a hiatus hernia (Saint’s triad).
Symptoms of Type II Hiatus Hernia
• Typical heartburn (47%)
• Dysphagia (35%)
• Epigastric pain (26%)
• Vomiting (23%)
• Anemia (21%)
• Barrett's epithelium (13%)
• Aspiration (7%).
Symptomatic gastroesophageal reflux disease (GERD) is frequently associated with a finding a sliding hernia. A number of procedures like Nissen’s fundoplication and its modification (the Toupet procedure), Hill’s procedure, and Belsey transthoracic repair have been described. Nissen’s fundoplication is, however, the simplest and most effective. Success has been achieved in performing the laparoscopic Nissen’s fundoplication, Hill’s repair, and Toupet procedure as well as thoracoscopic Belsey Mark IV. Laparoscopic Nissen’s fundoplication shows the most progress and has the potential of becoming a gold standard. It offers the opportunity for correction of the underlying anatomical and functional defect associated with GERD with lessened discomfort and hospitalization.
The indications are:
• Severe heartburn
• Refractory to medical therapy-symptoms present twelve weeks after therapy
• Noncompliance with therapy
• Development of complications like aspiration
• A type of hiatal hernia where the stomach is at risk of getting stuck in the chest or twisting on itself (paraesophageal hernia)
• Bleeding
• Barrett’s mucosa
• Stricture.
Relative contraindications include:
• Previous Hiatal or upper abdominal surgery
• Morbid obesity with left hepatomegaly
• Shortened esophagus
• Aperistalsis of the esophagus (achalasia, scleroderma, end-stage GERD).
Appropriate preoperative evaluation of esophagogastric junction is essential prior to perform laparoscopic fundoplication. Failure of surgery to control symptoms occurs in up to 10 percent of cases. It is a reflection that antireflux surgery has been inadvertently utilized for unrecognized cardiac, hepatobiliary, esophageal, or gastric etiologies.
Preoperative Evaluation
Preoperative investigation can be divided into mandatory and selective tests.
Mandatory
• Endoscopy UGI with/without biopsy
• Esophageal manometry.
Selective
• Barium swallow
• 24 hours pH monitoring
• Gastric studies.
At least 3 cm of the esophagus must be mobilized into the abdomen to ensure adequate intra-abdominal length for fixation. If a hiatal hernia is present, the crura are approximated with 2 to 3 sutures of No. Zero non- absorbable suture. The short gastric vessels are routinely divided along the upper one-third of the stomach using the harmonic scalpel. A 2 cm wrap is adequate with the incorporation of the esophagus into the wrap to prevent slippage. Postoperatively a chest X-ray is obtained in the recovery room to exclude a pneumothorax. Patients are kept on clear liquids on the day of surgery and soft diet the following day. The average length of stay is 2 days. Intraoperative complications may include injury to visceral organs, bleeding, pneumothorax, and vagal injury. Postoperative complications include wrap slippage.
Port Position
The patient is positioned supine on the operating table, and the surgeon works from the right side with the assistant on the left. Four 5 mm and one 10 mm laparoscopic ports are placed in the upper abdomen.
Port position in hiatus hernia
Operative Procedure of Giant Paraesophaegal Hernia
After exposing the hiatus, the herniated stomach is reduced into the abdomen using atraumatic graspers in a “hand-over-hand” fashion. Dissection is started for exposing the right and left crura of the diaphragm and mobilizing the esophagus. Sling is applied to retract the esophagus and facilitate mobilization of the esophagus posteriorly. Once the dissection is the complete appropriate size of the mesh should be taken and suture from below the esophagus to repair the defect.
Recommendation to Avoid Complication
• Ports should be placed high on the abdomen since much of the stomach will be up in the mediastinum.
• Compression stockings and subcutaneous heparin should be used to prevent deep venous thrombosis.
• Intra-abdominal pressures less than 15 mm Hg should be used.
• Prefer the bipolar for mobilization of the anterior gastroesophageal fat pad.
• It is important to remove the hernia sac from the mediastinum while avoiding entry into the pleural spaces.
• Stomach should be handled gently with graspers–the chronically herniated stomach perforates relatively easily.
• At the end of surgery perforations or leaks during dissection should be watched carefully.
