Page 67 - tmp

Laparoscopic Management of Hiatus Hernia
repair for hiatal hernia, by a single surgeon, over a period of percentages. Chi-square or Fisher’s exact test, whichever
10 years between April 2010 and March 2020 in Government appropriate, was applied for categorical data. A p-value of less than
Medical College, Srinagar. All patients were first examined by 0.05 was considered statistically significant.
Department of Gastroenterology. The patients were worked
up vis-à-vis symptomatic evaluation, barium meal, and results
esophagogastroduodenoscopy (EGD). Patients who had hiatus
hernia grade II, III, and IV were included in the study. Patients were A total number of patients included in our study were 42 after fulfilling
optimized for surgery and were kept fasting for 8 hours prior to the inclusion and exclusion criteria. Our study included 24 (57.14%)
the procedure. All patients underwent antibiotic prophylaxis and female and 18 (42.86%) male patients. The range of age was 22 to
prophylaxis for deep vein thrombosis. 60 years and the mean age of patients was 38.36 (SD 8.018). The study
was conducted over 14 (33.33%), 18 (42.86%), and 10 (23.81%) patients
Exclusion Criteria of type II, III, and IV hiatal hernia, respectively, as shown in Table 1.
• Medically unfit patients. Heartburn (32, 76.19%) was the most common symptom
• Patients with previous gastroesophageal surgery. followed by regurgitation (27, 64.29%) and epigastric pain
• Type I hiatus hernia. (25, 59.52%). Some patients also complaint of pulmonary symptoms
• Esophageal motility disorders. with chest pain (16, 38.1%) as most common symptom followed by
breathing difficulty (14, 33.33%). Two (4.76%) of the procedures were
Operative Technique converted to open repair owing to the nonavailability of bariatric
Procedure was started under general anesthesia; urinary catherization instruments as the patients were obese (BMI >30) and dissection
for monitoring and Ryle’s tube for stomach decompression were became difficult with the available instruments. Posterior cruroraphy
placed. Pneumoperitoneum (12–15 mm Hg) was created by Veress was done in all the patients. Nissen’s fundoplication was our primary
needle, and patient was placed in a reverse Trendelenburg position. choice performed in 37 (88.1%) patients. Few of our patients
Five trocars are inserted into the peritoneal cavity at the epigastrium, were comorbid and frail to whom Toupet’s repair (4, 9.52%) and
the right subcostal area, the left subcostal area, above the gastropexy (1, 2.3%) were performed, optimum to their conditions.
umbilicus on the middle abdominal line, and at 4–5 cm lateral to Out of 42, mesh was placed in 17 (40.48%) patients including all the
the midline in the left upper quadrant. Surgeon stands in-between type IV and few of the type III patients as shown in Table 2.
the legs (French position); primary and secondary assistants on The mean operative time was 126.90 (SD 12.781 minutes), with
either side of patient. Procedure was started with liver retraction operative duration decreasing with each procedure performed. The
and commencement of lesser omentum division keeping GEJ under mean blood loss and hospital stay were 62.14 (SD 17.605 mL) and
traction. Phrenoesophageal membrane was then dissected starting 4.60 (SD 1.127 days), respectively, as shown in Table 3.
from anterior aspect of hiatal opening resulting in mobilization of
esophagus and visualization of crura taking care of the two vagi. Table 1: Patient profile
Mediastinal dissection of esophagus was done for lengthening of
intraabdominal esophagus and reduction of hernia. Gastric fundus Total 42 (100%)
was then mobilized for the wrap by dissection of short gastric Gender
vessels, sometimes gastrosplenic ligament also. Esophageal hiatus Female 24 (57.14%)
was then narrowed down by suturing the crura with nonabsorbable Male 18 (42.86%)
sutures under a large 50–60 Fr bougie. About 2 cm anti reflex wrap Type of hernia
was then made by grasping posterior aspect of gastric fundus with II 14 (33.33%)
a blunt forceps placed posteriorly to the esophagus and calibrating
with a large 50–60 Fr bougie. In cases where total fundoplication III 18 (42.86%)
was not feasible, a partial posterior fundoplication was performed. IV 10 (23.81%)
In type IV and few of type III hiatal hernia, U-shaped mesh [mixed Mean Age 38.36 ± 8.018 (22–60) years
mesh polypropylene + polytetrafluoroethylene (PTFE)] was placed
around the hiatus and fixed with the tacks. No drains were placed, Table 2: Symptomatology and procedure
and procedure was completed by closing the port sites. Variable Type Frequency
Postoperative care was taken for the prevention of postoperative Total 42 (100%)
nausea and vomiting. Barium radiography was done on second Symptoms Heartburn 32 (76.19%)
postoperative day. Orals were started on postoperative day 2.
Patients were discharged once tolerating orals. Epigastric pain 25 (59.52%)
Regurgitation 27 (64.29%)
Follow-up Chest pain 16 (38.1%)
Patients were followed up at 1 month, 6 months, and then annually. Breathing difficulty 14 (33.33%)
The follow-up included routine general examination, barium
radiography, and EGD. Palpitation 18 (42.86%)
Type of plication Nissen’s 37 (88.1%)
Statistical Analysis Toupet’s 4 (9.52%)
The recorded data were compiled and entered in a spreadsheet Gastropexy 1 (2.38%)
(Microsoft Excel) and then exported to data editor of SPSS
Version 20.0. Continuous variables were summarized as mean ± SD, Crural closure Suture repair 25 (59.52%)
and categorical variables were expressed as frequencies and Mesh repair 17 (40.48%)

World Journal of Laparoscopic Surgery, Volume 14 Issue 3 (September–December 2021) 209