Paraesophageal hernia (PEH) in a 40-year-old patient: laparoscopic repair with reinforced cruroplasty

Patients with paraesophageal hernia (PEH) are usually symptomatic with GERD or obstructive symptoms, such as dysphagia. The underlying surgical principles for successful repair include reduction of hernia contents, removal of the hernia sac, closure of the hiatal defect, and an antireflux procedure. In this video, we show the case of a large paraesophageal hernia in a young male patient aged 40 presenting with dyspnea, thoracic pain and iterative dysphagia.

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Paraesophageal   hernia   (PEH)   in   a   40-year-old   patient:   laparoscopic   repair   with   reinforced   cruroplasty

Authors
B Dallemagne, J Marescaux
Abstract
Patients with paraesophageal hernia (PEH) are usually symptomatic with GERD or obstructive symptoms, such as dysphagia. The underlying surgical principles for successful repair include reduction of hernia contents, removal of the hernia sac, closure of the hiatal defect, and an antireflux procedure.
In this video, we show the case of a large paraesophageal hernia in a young male patient aged 40 presenting with dyspnea, thoracic pain and iterative dysphagia.
Keywords
Paraesophageal hernia, PEH, laparoscopic repair, reinforced cruroplasty
Media type
Duration
17'27''
Publication
2010-03
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E-publication
WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2881.htm

Paraesophageal   hernia   (PEH)   in   a   40-year-old   patient:   laparoscopic   repair   with   reinforced   cruroplasty

3. Anterior hernia sac dissection 01'35''
From the moment this dissection plane is found, the sac is progressively reduced from the right to the left crus or from the left to the right crus, but following the diaphragmatic opening. The risk of such maneuvers is to perforate the pleura if we are not in the appropriate plane. The benefit is to progressively identify the different components of the posterior mediastinum, and notably of the esophagus being totally invisible in the initial steps of the dissection. Typically, we can observe that the attachments of the hernia sac are quite thickened at the level of the left crus and it is necessary to divide this extremely thickened phrenogastric ligament in order to correctly reduce the sac towards the peritoneal cavity. In fact, this hernia sac corresponds to an enlargement of the phrenoesophageal ligament. This cleavage plane must be identified in relation to the muscular structures delimiting the hiatus. The avascular cleavage plane is confirmed and the hernia sac can be reduced as can be done for an inguinal hernia. As a result, the sac contents will be progressively reduced towards the peritoneal cavity and no attempt at reducing the sac elements in advance is made. In the current case, the sac is voluminous and well visible with the CO2 insufflation. As soon as it is reduced, the intramediastinal structures along with the location of the esophagus can be immediately identified. This extrasaccular approach is currently considered the safest standard approach: the intrasaccular approach has been abandoned totally. All the dissection is performed with the ultrasonic scalpel.
4. Posterior hernia sac dissection 03'50''
The next step is to reduce the posterior part of the sac, which itself is attached quite thickly to the base of the diaphragmatic crura. This step is necessary to obtain the hernia’s complete reduction. We can observe that the content of the hernia sac is oftentimes adipose, especially in morbidly obese patients. When the sac has been reduced, the different structures composing the hiatus and notably the right and left crura, are perfectly visible, and the cardioesophageal junction is progressively brought down underneath the diaphragmatic crura. As mentioned earlier, this can only be achieved through an appropriate freeing of the base of the left crus. This dissection on the left crus will facilitate the identification of the retroesophageal route, which is the next step in the dissection. Indeed, one of the objectives of the hiatal hernia treatment is not only to reduce the hernia sac, but also to remobilize the cardioesophageal junction to position it underneath the diaphragm without any tension; this is usually one of the difficult steps of this surgery as it offers the possibility to observe a short esophagus and difficulties crop up when it comes to reducing this junction. Once the retroesophageal route has been created, the junction can be fixed on a drain, which will facilitate retraction. Such a retraction is essential to mobilize as much esophagus as possible intramediastinally. The pleura along with the anterior and posterior vagus nerves are identified. All these maneuvers will contribute to lengthen the subdiaphragmatic segment of the esophagus. In case of short esophagus, this intramediastinal mobilization should sometimes be extended up to the carina. Sometimes, if the length is insufficient, other esophageal lengthening techniques such as a Collis gastroplasty must be considered. The aorta is identified and this view justifies the caution to be taken in the mediastinal dissection.
5. Sac dissection 05'54''
The next step is to resect the sac. This resection does not have to be necessarily complete. However, it has to render the cardioesophageal junction visible and free of any attachments. It is at the level of the cardioesophageal junction that the fundoplication will be carried out at the end of the procedure to prevent postoperative reflux. During the sac resection or the freeing of the cardioesophageal junction, it is sometimes uneasy to identify the anterior or posterior vagus nerves. It is not infrequent that these nerves are injured at this moment of the procedure. In this patient, the cardioesophageal junction is cleaned and part of the sac is completely resected. This exposure of the cardioesophageal junction is essential since it allows to assess the length of the subdiaphragmatic segment of the esophagus; an idea of the esophagus’ length cannot be obtained before this perfect exposure of the anatomical junction. The freeing of the sac, which used to be a difficult and hemorrhagic part of the procedure, has been comprehensively made easier by the use of new technologies, such as the ultrasonic scalpel or the Ligasure® device in this case. We have perfectly identified the cardio-esophageal junction. Releasing the traction on the loop that holds the junction allows to notice that the esophageal length is sufficient and we therefore proceed to the next step that is the mobilization of gastric fundus’ apex, a necessary step to perform the fundoplication. This step is performed even if the short vessels have been lengthened by this voluminous hiatal hernia. Indeed, a well-defined portion of the fundus must be used to create the fundoplication, and this portion is only usable if that apex was well mobilized. We see here that the posterior attachments of the fundus are still there despite the voluminous hiatal hernia. Therefore, this justifies the mobilization of the fundus’ posterior attachments. Once the gastric fundus has been correctly mobilized, we move on to a critical stage in the treatment of a voluminous hiatal hernia, the cruroplasty. The controversy persists between the pro-mesh surgeons and those who are more careful when it comes to using meshes in these procedures.
6. Crura reinforcement with Teflon pledgets 11'35''
Our alternative choice to simple suturing is reinforced suturing on Teflon pledgets. Two pledget strips are cut out and applied on the two diaphragmatic crura; these pledgets will maintain an interrupted suture of non-absorbable Mersuture® material. The posterior sutures are initially applied. They will allow to gradually re-calibrate the hiatal orifice. This is a difficult step in the procedure but it is indispensable. An intra- or extra-corporeal suture can of course be performed. The advantage of the Teflon pledgets is that there is almost no contact between the foreign body and the esophageal wall, as we know that close contact between the esophagus and the prosthesis results in erosion or intra-esophageal migration, occasionally leading to disastrous results. It is for that reason that we always defend the idea of using pledgets first, and it is only if the hiatal orifice is not suturable that a prosthesis should be placed. The posterior cruroplasty is achieved; it is not overly extended as it could cause an angulation of the esophagus. We will associate posterior stitches to anterior stitches while trying to find a relatively solid material to complete the recalibration of the hiatal orifice. At this moment in the procedure, it is sometimes recommended to use a calibration tube. We tend to try and close the hiatal orifice so that the diaphragmatic crura touch the esophagus without distorting it. In this young patient, the surgery that was performed can lead to gastroesophageal reflux, and it is therefore important to create an anti-reflux mechanism.
7. Floppy Nissen fundoplication 14'43''
As the patient is young, has a normal esophageal motility and has had his gastric fundus adequately mobilized, we will perform a floppy Nissen fundoplication. It is a tension-free valve that is 2cm long on its anterior portion and that will be fixed on its left inferior lateral stitch at the level of the esophagus, especially at the insertion point of the phrenoesophageal membrane, as it is a more resistant area than the esophagus’ anterior wall. This technique allows to systematically control the laxity of the anti-reflux valve, and we see here that the tissue on which the valve has been anchored is solid, fibrous and will probably perfectly stabilize the anti-reflux mechanism on the junction. In order to prevent early recurrences, a major risk following this surgery, we now routinely place a large absorbable Vicryl mesh, a mesh normally used to treat postoperative eviscerations. This large prosthesis will be applied on the diaphragm and around the esophagus; this is possible as the Vicryl mesh is completely absorbable in around 3 months. This method has allowed to avoid early postoperative hernias, usually linked to abdominal stresses, especially during the patient’s recovery. Since this type of protection has been used, no acute postoperative migrations have been observed. The patient will have a postoperative imaging check-up using a water-soluble contrast swallow on the first postoperative day, and the patient will be allowed to eat and drink from the first postoperative day as the anti-reflux mechanism’s stability below the diaphragm and a satisfying trans-fundoplication passage are confirmed by the check-up. The patient is discharged on the second postoperative day.