Laparoscopic treatment of hiatal hernia

WebSurg is a free virtual surgical university, accessible worldwide through the Internet. Our goal is to provide surgeons, scientific societies and the medical industry with the first online continuing medical education in laparoscopic surgery and information on the latest developments in laparoscopic surgery, including NOTES and robotics.

Browse the WORLD
Virtual University
English ▼

Laparoscopic   treatment   of   hiatal   hernia

Authors
B Dallemagne
Keywords
laparoscopy,gastroesophageal reflux disease,hiatal hernia,treatment
Media type
Duration
21'00''
Publication
2003-10
Popular
Favorites
Favorites Media
Audio
en
Subtitles
en
E-publication
WeBSurg.com, Oct 2003;3(10).
URL: http://www.websurg.com/doi-vd01en1513e.htm

Laparoscopic   treatment   of   hiatal   hernia

1. Case presentation 00'13''
It’s a female patient so the hiatus is not very high. I’m not that far from the umbilicus. Usually I’m trying to find the costal margin by checking this position. I’m very lateral for the grasping. That keeps the medial field free of too many instruments. This is the xiphoid process. I’m checking on the abdominal wall here and looking at the size of the liver. Because if I put my trocar too high, I will have some trouble with the liver. I’m going a little bit on the left side of the patient in order to avoid the liver as much as possible. When you are introducing or retracting instruments, you can go through the liver, which will start to bleed. So correct port placement is essential. I’m checking the position regarding the costal margin. This is the active port for my right hand in the direction of the hiatus, and then the retracting port on the right side of the patient is for the liver retractor. Again I’m checking the position and I’m always looking for the entry sites of trocars into the abdomen in order to avoid injuries. These are basic rules for laparoscopic surgery. I am working with 2 assistants. You can see where the right crus and left crus are. These are the hepatic branches of the vagus trunk. Here’s the nerve of Latarget going down there. Again in terms of basic instrumentation, I’m using this ultrasonic system. Here we don’t have any electric device like monopolar or bipolar systems. I don’t have a suction device. I use very basic instrumentation on the table. The instrument I’m holding in my hand is a disposable one. This device allows me to cut and coagulate. The fewer instruments you use in laparoscopy, the more successful it is and then you can avoid the risk of injury. We have a very good access on the right crus. With blunt dissection, I am on the right crus. Inside of the right crus I know that I can find the esophagus. As soon as you know where the esophagus is, then the procedure is safe. Sometimes you can have some fibers of the vagus trunk on the crura and here you see this may be the vagus trunk and it lies a bit on the crura. That’s why you need to use this blunt dissection initially in this area. Sometimes in thin patients, this may be uneasy since you need to reduce the amplitude of your movements and the procedure may become demanding. The vagus trunk is larger than the esophagus. For me the 1st essential landmark is the right crus and you have to clearly identify the right crus before starting any sort of dissection. We will now put the umbilical tape because here the esophagus is fragile and I don’t like to use the grasper. In most of the babies, we don’t have to mobilize the stomach because we don’t have a very large fundus so usually in such very young patients, in order to preserve as much as possible, then usually I’m not dividing the short gastrics. We have a very limited mobilization of the esophagus here. When you do this left dissection, you have to be very careful because sometimes the posterior trunk is coming in the field as you see. Identification of the structures is critical before mobilizing. Here is the orientation of the crura. Usually they are very vertical in most of the patients. In this young female patient with reflux disease, the crura are oblique. In this condition, the lower esophageal sphincter should be somewhere here. It’s lying into the chest instead of lying into the abdomen because of this orientation of the crura. It’s very typical in this type of female patient with reflux with very important symptoms, this type of anatomy is typical. Here we have to mobilize a little bit because the sphincter is there and the tendency is to put the valve here or we have to put the valve very high in this patient otherwise we’ll get recurrence. Here I’m trying to reproduce some sort of verticality of the crura before closing it. When you are passing this suture, the aorta is just there. On the other side, you see the vena cava. That can be a dangerous area. We are using X-stitches because I have the feeling that it reduces a bit the pressure and traction on each part. Not too much traction on the suture here in order to avoid cutting the crura. We had a lot of experience with the treatment of reflux disease in open surgery. Now we’re going to mobilize. At the lower part of this fat pad, we have the vessels. I’m trying to open the rear cavity now. All this dissection can be performed with scissors and clips, or even bipolar coagulation. We open the posterior aspect. Here we see clearly the posterior attachments. I had some recurrence with partial fundoplications. When I’m inside the abdomen, the valve is perfectly stable, well-placed, not too low on the esophagus and some people are refluxing through this valve. I keep Toupet or partial posterior fundoplications for very specific indications like scleroderma and redo surgery when the people who have a pseudo-achalasia (esophagus without any contraction), and in those patients, I don’t do a Nissen fundoplication. These are the very rare indications where I keep partial fundoplication. With experience some experts are moving from basic techniques like the Nissen-Rossetti to more sophisticated Nissen fundoplication. Experts try to simplify surgery and forget data obtained from the open surgery experience.