Laparoscopic treatment of a voluminous hiatal hernia

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Laparoscopic treatment of a voluminous hiatal hernia

Authors

Keywords

stomach,operation,gastroesophageal reflux disease,giant hiatal hernia,laparoscopy,large hiatal hernia

Media type

Surgical video

Duration

07'00''

Publication

2004-11

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E-publication

WeBSurg.com, Nov 2004;4(11).
URL: http://www.websurg.com/doi-vd01en1234e.htm

Laparoscopic treatment of a voluminous hiatal hernia

1. Hernia reduction 00'12''

Voluminous hiatal hernia represents a high risk for complication and recurrence. Preoperative contrast swallow is the most important evaluation to rule out shortening of the esophagus. The 1st step of the procedure consists of reducing and maintaining the hernia contents in the abdominal cavity. This often represents the most delicate operative step. The stomach is retracted caudally and to the left, thereby reducing the herniated stomach and the omentum into the abdominal cavity.

2. Hernia sac reduction into the abdominal cavity 00'48''

For that, it is sometimes necessary to add one more trocar to maintain the traction. After the reduction, we can see the empty hernia sac. The next step is removing the hernia sac into the abdominal cavity. For this we begin anteriorly in detaching the peritoneum from the hiatus and particularly from the anterior part of the crura. Then the peritoneum is detached from mediastinal attachments until the left and anterior sides of the esophagus are identified. The danger at this moment is to injure the left pleura so caution should be exercised. The next step is the posterior dissection. We begin after opening the pars flaccida of the lesser omentum preserving the accessory left hepatic pedicle. The dissection then continues anterior to the right crura and to the left crura using Harmonic scissors. You must continue the dissection until you reach the fatty tissue lateral to the left crura. To finish the dissection, it is usually necessary to expose the left crura anteriorly pulling the hernia sac caudally and to the right. Now it is necessary to detach the hernia sac from the lower esophagus. It is not always easy secondary to voluminous lipoma fixed around the lower esophagus, which is typically present. Using the Harmonic scissors, we free the esophagus anteriorly respecting the anterior vagus nerve. Then we dissect the lipoma laterally on the right aspect of the esophagus until we have exposed the cardia perfectly.

3. Repair of hiatus 03'46''

The limit of the cardia is determined by the left hepatic pedicle, which is a good landmark for the dissection. Posterior dissection of the lipoma is completed respecting the posterior vagal trunk in the right and left pleura. The next step is repair of the hiatus and the realization of a valve to prevent recurrence and gastroesophageal reflux. The closure of the hiatus is made using interrupted non-absorbable sutures with or without pledgets. Three to 5 stitches are applied for closing the crura leaving 1.5cm for the free mobilization of the esophagus. For the reinforcement, we use a rectangular 15 by 10cm polypropylene slit mesh with a 3cm keyhole for the esophagus. The mesh is fixed to the diaphragm with either clips or sutures.

4. Fundoplication 05'08''

For better visualization, we cut the triangular ligament and fix the body of the mesh posteriorly with 2 stitches to the diaphragm. The next step is creation of a valve. Care should be taken to perform the wrap around the esophagus and not over the hernia sac. We perform a circular 360 degree fundoplication of 1.5 to 2.0cm in length. The absence of folds in the fundus is ensured via back and forth movements posterior to the esophagus.

5. Recreation of superior phrenogastric ligament 06'16''

Interrupted stitches have to include the wall of the fundus anchoring it to the anterior wall of the esophagus. It is important to make sure that the fundoplication is tension-free. The last step is to recreate the superior phrenogastric ligament. The fundus is directly fixed to the prosthetic patch covering the diaphragm with 1 or 2 non-absorbable sutures.