Laparoscopic treatment of giant hiatal hernia with standard crural repair

This video demonstrates the key steps of the procedure for laparoscopic repair of a giant hiatal hernia. The patient is an 84-year-old woman with a long history of hiatal hernia. The patient was symptom-free until a few days before the intervention when the patient developed severe acute dysphagia, chest pain and dyspnea. Controversies exist regarding the type of crural repair that has to be performed in this type III hiatal hernia. We chose a standard crural repair with sutures based on the macroscopic aspect of the crura.

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Laparoscopic treatment of giant hiatal hernia with standard crural repair

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Abstract

This video demonstrates the key steps of the procedure for laparoscopic repair of a giant hiatal hernia. The patient is an 84-year-old woman with a long history of hiatal hernia. The patient was symptom-free until a few days before the intervention when the patient developed severe acute dysphagia, chest pain and dyspnea. Controversies exist regarding the type of crural repair that has to be performed in this type III hiatal hernia. We chose a standard crural repair with sutures based on the macroscopic aspect of the crura.

Keywords

laparoscopic, hiatal, hernia, dyspnea, type III

Media type

Surgical video

Duration

22'30''

Publication

2007-04

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E-publication

WeBSurg.com, Apr 2007;7(04).
URL: http://www.websurg.com/doi-vd01en2101.htm

Laparoscopic treatment of giant hiatal hernia with standard crural repair

1. Dissection of hernia sac, right and left crus 00'15''

The patient is quite an old woman with severe symptomatology so that’s an indication for surgery, she can’t breathe and she can’t eat anymore so surgery is necessary even if she’s 85 years old! We’re using the usual port placement, nothing compared to a simple reflux disease. This is the view within the abdomen, see this very large hiatus and there is some sort of lobulation and volvulus of part of the stomach within the mediastinum. We can understand that this woman is not able to eat easily any more and probably because of the dilation of this pouch within the chest, she has some problems with breathing, this big part of the stomach is inside and you see this bubble, that’s certainly something that explains the symptomatology. We are immediately going to go on the hiatus and work on the hiatus, and try to reduce all the sac. We will not work inside there because we cannot find our way, but we will work alongside the hiatus. There is also an artery here, left hepatic artery, so we will try to preserve that.

2. Excision of hernia sac 01'40''

Sometimes in the huge hiatal hernias, it is difficult to preserve that. Instead of going this way, I will go outside and work between the mediastinal structures and the sac. The main goal is to find this cleavage plane between the diaphragm and the sac. That’s a disease of the diaphragm, it has nothing to do with the disease of the GE junction that we did yesterday. You see that I have opened this plane between the diaphragm and the sac. You’re actually splitting between 2 layers, the peritoneal layer which is held by the grasper and the layer outside, which represents the reflection of the endo-abdominal fascia. Why are you operating in that plane rather than outside the endo-abdominal fascia? I know that if I am working outside, I can reach for the esophagus quite easily and without any risks. While I am applying traction, I am reducing all the hernia content. The usual problem is to work on the lower part of this left crus and this is a crucial point because as soon as I will divide that, I will get some more length within the abdomen. Do you always start in the right crus, because usually when I can reduce the sac, I start in the right crus but when I can’t reduce it I prefer to start in the left crus, so I go behind the esophagus. It’s easier because I’ve already dissected the left crus. This is the most severe fixation of the sac usually. This is never going to come down while the sac is inflated by the pneumoperitoneum, it’s being pushed up by the pneumoperitoneum. You are showing attention to keep the peritoneum on the crus and that is important. The advantage with regards to the sac is that I don’t have to look for the esophagus initially, I am above the sac and I’m just bluntly dissecting the upper part of the sac. There are a lot of adhesions in the mediastinum that we have to clear. We are working in quite low pressure, 12mm Hg so not a very high pressure. If I do a hole in the pleura, it is better to leave it open because if you try to close it, you can create tension and pressure in the pneumothorax. I’m trying to clear the left crus. The aorta should be somewhere here so the esophagus should be in this area. I will go back on the right side now. The problem with the stomach is that initially the nasogastric tube can pass down the stomach and we have dilation of the stomach, which is a bit annoying. We are progressing quite well, we can see that the pleura is there, the sac is just on the right side, we have to work in this plane. It was mostly developed on the right side of the patient so mostly there. We are still working in the mediastinum and we were looking for the esophagus, and as you can see the hernia was developed mostly in the right part of the mediastinum so we found the esophagus in this position, a little bit lifted on the left side of the patient. The access to the esophagus is there. The fact that we have been working outside the sac, we are able to dissect the esophagus in a sort of usual fashion. Now the goal is to try to bring back everything into the abdominal cavity. It looks very short so far, we have to do quite a lot of extensive mobilisation/dissection. So the vagus trunk is there, this has nothing to do with the vagal trunks, I can divide it. I am doing quite a lot of blunt dissection before deciding to divide. I know that the pleura is not that far so I am freeing all these adhesions progressively. I am not working on the GE junction at this stage because I know that I can’t reduce it easily. I prefer to work within the mediastinum and progressively go to the GE junction and trying to reduce the junction. The aorta is not that far. I will probably have to divide this artery because I can’t get proper access to the hiatus and I can’t reduce it. That is the rare indication where I have to divide the artery. You see that I am working on the gastric side and not the hepatic one because if I have a problem, I will have retraction and sometimes it’s hard to pull it back from there. It is evident that we need to do that because I am opening the space, the question of safety of the operation is also very important. Sometimes when you go in for redo fundoplications, the left lobe is very atrophied. Usually I try to be very conservative. I know that my crus is there because I have my right crus there. Progressively we are getting back to a normal anatomy. There is some oozing there, we will check that from the other side because I have opened my space you see. There is some part of the sac still attached to the GE junction so I have to clear that afterwards, but I like this tape because it is really atraumatic so I prefer to use that. I often find it very hard to tell where the GE junction is in these people and I almost always in a peri-esophageal use an endoscope intraoperative. It’s not really the GE junction because there is some part of the sac around this but it’s convenient to pull on the esophagus because it’s really atraumatic. Usually all these sac adhesions when you grasp them, you make them bleed and when they start to bleed you can’t see anything any more. You have to keep the field as clear as possible. I think this is not the vagus down there because I saw it around the esophagus. I will clear this posterior aspect, I am just checking that my trunk is still with me. So what is the diet like for the patient? I recommend to be very careful during 8 to 15 days with a semi-liquid diet, then after 2 weeks they can start to eat a little bit more solids; at 1 month they can usually start to eat normally. That’s the usual outcome for this type of patient, and even for the reflux.

3. Mobilization of fundus 16'20''

Step by step we are getting this back into the abdominal cavity. Now we are going to work on the sac, because I want to identify a little more the junction. Do you think that extensive dissection of the esophagus in the mediastinum has some influence in dysphagia? I think so, the problem is that you can’t appreciate that properly in this sort of patient because they have dysphagia initially, usually they say it improves after the operation because they can swallow, and they can’t or barely do so before the operation. Based on the experience of reflux, we know that we are impairing the esophageal motility, during 3 to 4 weeks after the operation. Initially, some years ago, we did a manometric study, at day 2, day 15, day 30 after the fundoplication and we can see that 2 weeks after surgery you don’t have esophageal peristalsis anymore, it’s probably related to the mobilisation. I don’t think this is the vagus trunk here.

4. Crural repair 17'50''

We are going to prepare a little bit the gastric fundus in order to be ready for the fundoplication because as you know I mobilise in every patient. It also allows me to have a better look at the GE junction, so I like to do that even for these large hernias where the fundus is quite large. This is the same technique as for the reflux, the posterior aspect has been opened and you see these vessels are very long, they are not short any more but I like to divide them so I can get my landmarks. Otherwise you don’t know where the fundus is, or the top of the fundus. By doing that, I have cleared the anatomy a little bit more. There is some lipoma there, I don’t know what I am going to do with that, we will see if it reduces.

5. Toupet fundoplication 20'30''

It’s on the stomach you see. The crura are not that bad in this old woman, look at this one. Let’s take a good bite. The right crus is a little thin. When you talk about a massive hiatal hernia, are we talking about the defect or about the contents? In this case it was the contents because the defect is pretty tame really. Another concern with the mesh and fixation of the mesh is the tacker; you may have heard of complication of the mesh with the tacker in the pericardium and some deaths because people are putting taker everywhere, they provoke a cardiac tamponnade which leads to death, so again it’s not a simple operation, everything is important in this area. I will put another stitch because that one was not very good. We will check what we have done. We put some traction so we have the size of the esophagus and then we release the traction. I will do a Toupet. You would do a very short 1cm Nissen? I prefer the Toupet because I have the feeling that it would close a little more the area. I just do not want to have an over powerful mechanism. With experience in laparoscopy, you can feel things, the same way as in open we were feeling the vagus trunks with the finger. I don’t think it’s too tight, little anti-reflux repair just to prevent the regurgitation. No bleeding is observed.