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Technique for laparoscopic treatment of giant hiatal hernias
Authors
Abstract
The description of the technique for laparoscopic treatment of giant hiatal hernias covers all aspects of the surgical procedure used for the management of voluminous hiatal hernias.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure of hiatal region, dissection of hernia sac, mobilization of esophagus, hiatus repair, fundoplication, gastropexy.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exposure of hiatal region, dissection of hernia sac, mobilization of esophagus, hiatus repair, fundoplication, gastropexy.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-02
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WeBSurg.com, Feb 2001;1(02).
URL: http://www.websurg.com/doi-ot02en005.htm
URL: http://www.websurg.com/doi-ot02en005.htm
Technique for laparoscopic treatment of giant hiatal hernias
1. Introduction
The first series describing the laparoscopic approach for the repair of giant hiatal hernias (HHs) was reported by Cuschieri (1993). A large number of publications have since confirmed the feasibility of the laparoscopic approach.In an attempt to reduce the risks of recurrence, the use of prosthetic material to reinforce the crural repair or to simply plug the crural defect has been proposed.
2. Anatomy
• Gastroesophageal junction
1. Inferior part of the lesser omentum 2. Left lobe of the liver
3. Esophageal hiatus
4. Diaphragm
5. Pleura
6. Spleen
The normal gastroesophageal junction is composed of a 2 to 5 cm segment of esophagus fixed below the hiatus to the diaphragm, crura and stomach by ligamentous attachments. Maintenance of normal relationships between these structures is essential to the integrity and function of antireflux mechanisms.
• Local anatomy
1. Liver attachments2. Phrenoesophageal ligament
3. Gastrophrenic ligament
4. Gastrosplenic ligament
5. Short gastric vessels
6. Left kidney
7. Toldt's fascia
8. Crura
• Pathophysiology
1. Heart and pericardium2. Esophagus
3. Lungs
4. Peritoneum
5. Diaphragm
6. Pleura
Intramediastinal herniation can cause cardiac (1) or pulmonary compression (3) in association with a shortened thoracic esophagus (2).
Insufflation of the abdominal cavity may intensify the phenomenon of mediastinal compression.
3. Classification
• Classification
1. Thoracic esophagus2. Thoracic cavity
3. Right crus
4. Left crus
5. Abdominal esophagus
6. Fundus of the stomach
Three types of hiatal hernias may be observed.
Giant HHs represent an advanced form of type III HHs.
Patients with giant HHs have a high risk of complications and recurrence after surgical treatment (Carlson et al., 1998).
• Type I hiatal hernias
Ninety-five percent of all patients with HH have type I hernias characterized by slippage of the gastroesophageal junction through the esophageal hiatus into the mediastinum.• Type II hiatal hernias
Type II HHs represent 5% of all HHs. In these patients, the phrenoesophageal ligament has migrated into the mediastinum either anterior or lateral to the esophagus, with the cardia remaining in its normal position. The hernia generally contains the fundus of the stomach.• Type III hiatal hernias
Type III HHs combine both type I and II HHs.Giant HHs represent an advanced form of type III HHs. They share the following characteristics:
- major esophageal hiatus enlargement (>= 8 cm in diameter [Frantzides et al., 1999]);
- elongation and weakening of the crura;
- intrathoracic migration of the gastroesophageal junction including part or all of the stomach;
- occasionally, migration of the spleen and large bowel into the intramediastinal or intrathoracic hernia sac;
- occasionally, esophageal shortening.
4. Types of shortening
• Classification
1. Thoracic esophagus2. Thoracic cavity
3. Abdominal esophagus
4. Esophageal hiatus
5. Abdominal cavity
Esophageal shortening may be associated with intramediastinal migration.
Three types of short esophagus can be distinguished (Swanstrom et al., 1996).
• Type I
This involves the migration of the gastroesophageal junction into the mediastinum, resulting in a Z-shaped esophagus.The gastroesophageal junction can be easily brought back into the abdominal cavity with minimal dissection.
• Type II
The esophagus is shortened and fixed to the mediastinum.The cardia can still be brought back 2 cm below the esophageal hiatus after an extensive mediastinal dissection.
The gastroesophageal junction can only be reduced after extensive dissection.
• Type III
It is impossible, despite extensive dissection, to bring the cardia back to 2 cm under the diaphragm and create a standard fundoplication.In these patients, the gastroesophageal junction cannot be reduced.
5. Indications
Giant HHs are associated with a high risk of complications such as compression, gastrointestinal hemorrhage due to gastroesophageal ulceration, stricture, and perforation. Therefore, most authors agree that surgical treatment is indicated (Maziak et al., 1998). Indications for the laparoscopic approach
Asymptomatic hernias:
- young patients or patients in good medical condition.
Symptomatic hernias:
- compression of mediastinal organs (causing dyspnea, arrhythmias, chest pain);
- dysphagia (which can be severe in cases of gastric volvulus);
- gastrointestinal hemorrhage (causing hematemesis, melena, anemia);
- high obstruction induced by stricture or volvulus;
- associated peptic esophagitis.
Contraindications for the laparoscopic approach
Absolute contraindications:
- abdominal or mediastinal perforation.
Relative contraindications
- single or multiple recurrences in patients with multiple abdominal scars (the thoracic route may be indicated in these patients),
- Barrett’s esophagus.
6. Preop management
• Chest X-rays
The presence of abdominal organs in the mediastinum or thorax (seen on postero-anterior and lateral chest X-rays) raises the suspicion of a large hiatal hernia. • Esophagogastroduodenoscopy
Esophagogastroduodenoscopy allows:- assessment of the esophageal mucosa;
- localization of the cardia;
- confirmation of the absence of gastroduodenal ulceration.
Note: This examination is sometimes impossible in patients with strictures or volvulus.
• Esophageal manometry
Preoperative esophageal manometry is not considered mandatory by most authors.If utilized, it often reveals a decreased pressure at the lower esophageal sphincter (LES) as well as poor esophageal contractions in cases of giant HHs.
It also allows assessment of the length of the esophagus between the superior esophageal sphincter and the LES; this averages 20.5 cm. Esophageal shortening can be demonstrated if it exists, thus influencing the decision regarding medical or surgical treatment.
• Contrast examination
Contrast swallow and follow-through:- precisely assess the anatomical modifications that have occurred,
- distinguish HHs from pericardial cysts or Morgagni hernias.
Note: Unsuspected hiatal anomalies have been reported on contrast examinations in a significant number of asymptomatic patients (Wu et al., 1999).
• Other examinations
- large bowel contrast enemas, CT-scans or MRIs are sometimes necessary to complete the workup.- in cases of very large hiatal hernias, pulmonary function tests are sometimes necessary to define the functional capacity of the respiratory system before a surgical procedure.
7. Operating room set-up
• Patient
The patient is prepared and placed in a supine position on the operating table and draped in the usual sterile manner.It is mandatory to place a dual lumen gastric tube into the stomach to decompress it. However, this can sometimes be very difficult, if not impossible, before the hernia is reduced.
• Steep table position
To enable a steep reverse Trendelenburg position (30°), especially in obese patients, the patient must be securely positioned.• Team
1. The surgeon stands between the legs of the patient.2. The first assistant stands on the patient's left.
3. The second assistant stands on the patient's right.
4. The scrub nurse stands on the surgeon's right.
• Equipment
1. The first monitor is used by the surgeon and the first assistant.2. The second monitor (optional for some) is useful for the second assistant.
The laparoscopic and video units are placed on the patient's right.
8. Trocar placement
• Landmarks
1. Xiphoid process 2. Costal margin
3. Midline
4. Midclavicular line
5. Anterior axillary line
• Optical device
A: 0° laparoscopeThe 10-12 mm optical trocar is introduced first, halfway between the xiphoid process and the umbilicus.
Our technique requires the optical trocar to be placed rather high on the xipho-umbilical line, contrary to the opinion of some authors (Frantzides et al., 1999), because it offers excellent visualization of the hiatal region and mediastinum using a 0° laparoscope.
• Operating devices
C: Grasping forcepsE: Ultrasonic scalpel or scissors for diathermy, clip applier, suction-irrigation device, needle-holder
The trocars (usually 5 mm) are placed under direct vision in subcostal position on the right and left midclavicular lines.
• Retracting devices
B: Liver retractorD: Atraumatic grasper
The other trocars, usually 5 mm, are placed under direct vision as follows:
- to the left of the xiphoid process (liver retractor),
- in left subcostal position on the anterior axillary line (retractor).
• Additional trocar
F: RetractorThe use of an additional 5 mm trocar is often necessary to allow better exposure of the hiatus.
This trocar is usually placed on the midclavicular line 8 to 10 cm under the right subcostal trocar.
9. Instrumentation
• Placement
A: 0° laparoscopeB: Liver retractor
C: Grasping forceps
D: Atraumatic grasper
E: Ultrasonic scalpel or scissors for diathermy, clip applier, suction-irrigation device, needle-holder
F: Retractor
• Optical device
A: 0° laparoscopeMost procedures are performed using a 0° laparoscope, although a 30° laparoscope may sometimes be useful if visualization is inadequate.
• Operating devices
C: Grasping forcepsE: Ultrasonic scalpel or scissors for diathermy, clip applier, suction-irrigation device, needle-holder
• Retracting devices
B: Disposable liver retractorD: Atraumatic grasper
F: Reusable liver retractor
Note: We favor a reusable liver retractor that can be introduced in a 5 mm trocar.
10. Exposure/hiatal region
• Pneumoperitoneum
It is established with the usual precautions at a maximal intraperitoneal pressure of 12 mm Hg. This minimizes the risk of cardiac compression, pneumomediastinum, cervicofacial subcutaneous emphysema and hypercapnia. Exposure of the hiatal region is facilitated by placing the patient in a steep reverse Trendelenburg position (30°). In the first step of the procedure, the surgeon reduces and maintains the hernia contents in the abdominal cavity. This often represents the most delicate operative step.• Liver retraction
The left lobe of the liver is retracted cephalad and to the patient’s right with an atraumatic retractor introduced through the trocar placed on the left of the xiphoid process (trocar B).Alternatively, a liver retractor may be placed through trocar C, in which case it is necessary to place a mediastinal retractor via trocar B; consequently, trocar F becomes an operating trocar.
• Retracting the stomach
The stomach is then retracted caudally and to the left, thereby reducing the herniated stomach and omentum into the abdominal cavity. An atraumatic forceps is inserted through the left lateral trocar (D) to help complete this step.Once reduced, the stomach must be maintained in the abdominal cavity.
• Retracting the lesser omentum
Although the body of the stomach is reduced into the abdominal cavity, the cardia often remains in the mediastinum together with the superior part of the lesser omentum and the gastrosplenic ligament, including the short gastric vessels.1. Inferior portion of the lesser omentum
2. Superior portion of the lesser omentum
11. Dissection of hernia sac
• Principles
The hernia sac may be left in place, resected or reduced into the abdominal cavity. We prefer the last option. Reduction of the hernia sac is facilitated by maintenance of the stomach in the abdominal cavity. It may require the use of an additional 5 or 10 mm trocar for retraction placed on the lower lateral part of the left hypochondrium (via D). Reduction of the hernia sac into the abdominal cavity, with or without resection, is mandatory according to certain authors (Edye et al., 1998), as it facilitates the dissection of the esophagus and reduces the overall operative time.• Anterior dissection
1. Right crus2. Mediastinal pleura
3. Hernia sac
The hernia sac is identified once the stomach has been reduced into the abdominal cavity and dissected off the hiatus anteriorly and left laterally. The hernia sac is gradually detached from the mediastinum until the left and anterior sides of the esophagus are identified. The left pleura and the left vagus nerve must be identified and preserved during this dissection.
The hernia sac is then detached from the left crus and gradually mobilized from the left posterior aspect of the esophagus. The phrenogastric ligament is divided to facilitate extensive mobilization.
• Right posterior dissection
1. Left hepatic pedicle2. Right crus
Once the hernia sac has been reduced from the left lateral aspect of the esophagus, the forceps introduced through the left lateral trocar (via D) are used to grasp the lesser omentum on the right side of the gastroesophageal junction and exert an anterior and left lateral traction.
The hernia sac is then detached from the right crus after the division of the avascular part of the lesser omentum. The hernia sac can be retracted cephalad and laterally between the esophagus and the aorta. It must be gradually detached from the right crus, the right aspect of the esophagus, the posterior vagus nerve, and further cephalad from the right pleura.
• Left posterior dissection
1. Esophagus2. Left crus
3. Gastrosplenic ligament
4. Hernia sac
Division of the short gastric vessels is not always necessary to maintain the gastroesophageal junction and lower esophagus in the abdominal cavity. Division of the gastrophrenic and phrenoesophageal ligaments is nevertheless essential.
Division of the short gastric vessels is seldom required to prepare the stomach for a fundoplication because the fundus is usually very mobile.
• Periesophageal dissection
1. Posterior vagus nerve2. Right crus
3. Retroesophageal window
4. Left crus
Once the hernia sac has been detached from the esophagus and mediastinum, it is either brought back into the abdominal cavity or resected, depending on the size of the sac.
A large associated lipoma is usually found around the lower esophagus. It must be removed to allow anatomical dissection of the esophagus. The posterior vagus nerve is left in close proximity to the esophagus to avoid any injury during the dissection and posterior cruroplasty.
12. Mobilization/esophagus
• Principles
Mobilization of the esophagus is necessary to ensure that it remains in the abdominal cavity without any traction.A bougie should not be introduced into the lower esophagus during this step.
• Dissection of lesser omentum
1. Superior portion of the lesser omentum2. Left hepatic pedicle
Mobilization and dissection of the superior portion of the lesser omentum with or without the left hepatic pedicle may be useful. In its anatomical position, when it is preserved, the accessory left hepatic artery constitutes an excellent landmark for the cardia and the lower esophagus.
• Dissection of lower esophagus
1. Retracted hernia sac2. Esophagus
It is often necessary to dissect the lower esophagus from its mediastinal attachments as well as from the hernia sac to bring the cardia back into the abdominal cavity.
In case of short esophagus division of the vagus nerves may be necessary in order to gain 1 or 2 cm of length. In this setting, consideration should be given to a pyloromyotomy or pyloroplasty (Jobe et al., 2002).
13. Major principles
In order to repair the hiatal defect, the diaphragmatic crura are approximated.A fundoplication is created with the addition of a gastropexy for some authors or even a gastroplasty when the esophagus is short. The hiatus can be repaired by suturing the crura (with a prosthesis if needed).
1. total or partial fundoplication created;
2. abdominal anterior and/or diaphragmatic gastropexy created;
3. Collis gastroplasty (Swanstrom et al., 1996).
14. Hiatus repair
• Principles
To prevent intrathoracic migration of the esophagus into the mediastinum, the hiatal opening must be narrowed. It is repaired either with a simple suture or a pledgeted suture and/or a prosthetic mesh.• Types of prosthesis
• Expanded PTFE mesh
Most authors use the Expanded PTFE® mesh in the treatment of giant HHs because it is flexible and inert. In various experimental studies (Lamb et al., 1983; Frantzides et al., 2002), it offered the major advantage of producing fewer adhesions, probably because of its smooth texture in comparison with other types of mesh.The Expanded PTFE® mesh is nevertheless difficult to manipulate and to fix, especially when using staples. The fact that it reduces adhesion formation may be a drawback since adhesions are thought to facilitate the fixation process of the cardia and stomach under the diaphragm.
• Polypropylene mesh
The Prolene mesh is useful due to the properties of the material itself:- it is easy to manipulate and position, and it is easy to fix to the diaphragm,
- it makes a gastropexy easier.
The Polypropylene mesh induces adhesion formation to neighboring organs and may eventually cause damage to the esophagus and stomach. Several isolated publications (Kuster and Gilroy, 1993) and certain series such as Pitcher et al. (1995) have demonstrated that these risks are minor.
Edelman also reports a series on 5 HHs repaired laparoscopically with a large polypropylene prosthesis (Surgipro Mesh, Autosuture, Tyco, Norwalk, CN) where the cardia was fixed to the prosthesis along with a gastropexy (Edelman, 1995).
• Mersilene mesh
Kuster and Gilroy, 1993.• Simple cruroplasty
1. Right crus2. Left crus
The hiatal defect is closed posteriorly to lengthen the intra-abdominal portion of the esophagus and expose it to the positive pressure of the abdominal cavity (Skinner and Belsey, 1967).
The crural sutures are first placed posterior to anterior. Using interrupted non-absorbable sutures (00 Polyester) with or without pledgets, 3 to 5 stitches are applied behind the esophagus.
When the hiatal defect is huge, 1 to 3 sutures are also applied anterior to the esophagus. At the end of the cruroplasty, there must be no impingement on the esophagus. For this reason, some authors suggest performing the cruroplasty following the introduction of an inflatable bougie or 50 French tube into the esophagus and stomach (Frantzides et al., 1999).
• Cruroplasty reinforced by mesh
A rectangular 15 cm X 10 cm polypropylene mesh with a 3 cm hole in its center and an anterior slit may be used to reinforce the cruroplasty.The mesh is introduced into the 12 mm optical port, pushed into the peritoneal cavity, and placed around the esophagus. It is then fixed posteriorly onto the crura and anteriorly onto the diaphragm where the 2 arms of the mesh are crossed to prevent a defect at the slit level.
The mesh is fixed to the crura and diaphragm using either staples or non-absorbable sutures.
• Tension-free patch repair
The tension-free repair described by Paul et al. (1997) consists of applying a polytetrafluoroethylene (PTFE) mesh on each side of the esophageal hiatus anterior to the esophagus.15. Fundoplication
• Indications
Many authors list the following indications for the creation of a fundoplication:- reflux (often asymptomatic) is present in 30% to 40% of cases of giant HH (60% of the cases of type III HHs);
- reflux subsequently develops in 20% of operated patients who had no preoperative abnormalities (Willekes et al., 1997; Casabella et al., 1996: Frantzides et al., 1999);
- fundoplication reduces risks of recurrence (Cuschieri, 1993).
• Anti-reflux mechanism
We perform Nissen-Rossetti, Nissen or Toupet partial fundoplication techniques. Care should be taken to perform the wrap over the esophagus and not over the hernia sac, since the latter may cause an intrathoracic migration of the wrap.
16. Gastropexy
• Techniques
It may be performed:1. by directly fixing the fundoplication to the crura or prosthetic patch;
2. by fixing the cardia and/or fundus to the diaphragm;
3. by creating an anterior gastropexy to the anterior abdominal wall.
An anterior gastropexy has not been shown to significantly reduce the recurrence rate (Williamson et al., 1993).
• Fixation to crura
1. Right crus2. Fundoplication
3. Left hepatic pedicle
Once created, the fundoplication is fixed to the crura using 2 or 3 non-absorbable sutures. This is only possible when the crura are of good quality.
The fundoplication can also be fixed to the prosthetic patch that covers the crura.
• Fixation to diaphragm
1. Exposed esophagus2. Right crus
The fundus is directly fixed to the diaphragm or to the part of the prosthetic patch covering the diaphragm with 1 or 2 non-absorbable sutures in order to re-create the superior phrenogastric ligament.
• Anterior gastropexy
Anterior gastropexy has been proposed (Maziak et al., 1998; Swanstrom et al., 1996) to limit the risks of intrathoracic slippage, particularly where a shortened esophagus is involved.The use of a gastrostomy as an anterior gastropexy has been proposed by Edelman. This procedure, however, exposes patients to unnecessary risks for postoperative complications (1 patient died from peritonitis; Edelman, 1995).
17. Postop management
At the end of the procedure, the mediastinal space is drained only if there is persistent hemorrhagic oozing.A chest X-ray should be performed when operative difficulties are encountered to rule out a pneumothorax or to assess the severity of a pneumomediastinum.
Anesthetic reversal should be smooth to avoid increased abdominal pressure, with its attendant risk of recurrence. For similar reasons, it is particularly important to avoid nausea or vomiting.
The dual lumen gastric tube is left for 24 to 48 hours to minimize risks of gastric dilatation.
Oral intake is resumed once the gastric tube has been removed.
A quick resumption of physical activity is possible once postoperative discomforts have disappeared. Strenuous exertion must be avoided for 1 month.
A rapid return to work is possible as long as strenuous activity is avoided.
18. Results
The feasibility of the laparoscopic approach has been demonstrated in a large number of publications. So far, the results seem to be equivalent to those of open surgery (Martin et al., 1997). However, the laparoscopic approach is still controversial for some authors who prefer an open abdominal or an open thoracic approach to treat type III HHs (Maziak et al., 1998; Hashemi et al., 2000).
Recovery
Postoperative hospital stay is usually much shorter than in the open approach, due to reduced postoperative discomfort, and decreased cardiopulmonary complications:
- open surgery: 9 to 10-day hospital stay (Ellis et al., 1986; Hashemi et al., 2000)
- laparoscopic surgery: 3-day hospital stay in 93% of cases (Willekes et al., 1997; Hashemi et al., 2000).
Recurrence rate
This is the major problem in the surgical treatment of giant HH (Khaitan et al., 2002). The recurrence rate varies from 6% to 50% depending on the types of HH and investigations utilized to determine the diagnosis. A large number of recurrences are totally asymptomatic and only found during a follow-up contrast swallow. The risk of recurrence is increased if there is a large pressure gradient between the abdominal and thoracic cavities. Physical exertion, coughing and obesity therefore predispose to recurrence, as do a weakened crura and a short esophagus. Ackermann et al. (1989) reports a radiological recurrence rate of 50% after open surgery.
Huntington (1997) reports a radiological recurrence rate of 6% after laparoscopic surgery with an average 12-month follow-up whereas Hashemi and DeMeester report a rate of 42% with an average 17-month follow-up (Hashemi et al., 2000). The goal of laparoscopic surgery is to reproduce the results of the open approach: recurrence rates of around 10% for Williamson et al. (1993), 15% for Hashemi and DeMeester (Hashemi et al., 2000), and 14% for Ellis et al. (1986) with an average follow-up of 61 months.
Morbidity rate
The morbidity rate in open surgery is 14%, keeping in mind that certain authors do not consider splenectomy (Ellis et al., 1986) or prolonged dysphagia (Menguy, 1988) complications. For Hashemi and DeMeester, there seems to be no difference in morbidity rates between the laparoscopic and open approach (Hashemi et al., 2000).
Mortality rate
The average mortality rate for open surgery in several series is 3% (Huntington, 1997). For Hashemi and DeMeester, there seems to be no difference regardless of the approach (Hashemi et al., 2000).
19. Conclusions
The laparoscopic approach offers surgeons an alternative to the treatment of giant HHs. The procedure is difficult to perform. The recurrence rate, which is elevated in some series (Hashemi et al., 2000), demonstrates the difficulty of reproducing open surgery's results laparoscopically.Nevertheless, the laparoscopic approach:
- provides better visualization of the hiatal region;
- offers an acceptable morbidity rate;
- is associated with a more rapid recovery rate (Hashemi et al., 2000);
- provides for better postoperative comfort;
- reduces cardiopulmonary complications.
20. Reference
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