Teflon pledgets cruroplasty and vicryl mesh reinforcement for rolling hiatal hernia repair

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摘要

This video shows the laparoscopic treatment of a rolling hiatal hernia in a 71-year-old female patient with a previous history of upper GI symptoms. Teflon pledgets cruroplasty and vicryl mesh reinforcement are demonstrated.

關鍵字

Teflon pledgets cruroplasty, vicryl mesh reinforcement, rolling hiatal hernia repair

媒體類型

期間

14'43''

刊物

2011-03

普通的

最愛

音訊

副標題

數位出版

WeBSurg.com, Mar 2011;11(03).
URL: http://www.websurg.com/doi-vd01en3223.htm

Teflon pledgets cruroplasty and vicryl mesh reinforcement for rolling hiatal hernia repair

1. Clinical case presentation 00'19''

We have a 71-year-old female patient with a previous history of upper GI symptoms. A few months ago, she was admitted for vomiting and bleeding from the stomach, and so she had an endoscopy that showed a large hiatal hernia with almost all the stomach within the chest. She was treated for that, but kept on with symptoms of pain, dysphagia, problems when trying to eat normal food. That is why she has come to the department for an evaluation. Due to these symptoms, we decided to do surgery.

2. Reduction of herniated omentum 01'02''

We see in the abdomen that all the greater omentum was inside the chest. We have reduced the omentum. We are not trying to reduce the stomach, because usually it does not work. All the stomach is in the chest.

3. Division of pars flaccida 01'21''

We start to divide the pars flaccida of the lesser omentum.

4. Finding of cleavage plane 01'26''

At this point, we are trying to find the cleavage plane between the hernia sac —in this periesophageal hernia there is a hernia sac— and the normal mediastinal structures. The assistant holds what we think to be the part of the sac, and we will dissect within the mediastinum to find the cleavage plane. Sometimes it is difficult to find exactly the right plane, so we have to go step by step, using blunt dissection. Normally, when we are on the right plane, there is an easy cleavage plane that should show that you are at the right level. The idea at this point is to get all the sac, and then, once we have reduced the sac, we will probably see that all the stomach is back inside the peritoneal cavity. I do not know yet if I am in the right plane, because there can be different layers at this point on the thoracic fascia. The base is to stay very close to the crus, because usually at this point you can get the right plane. It is very important to have a perfect traction on the sac, because it helps to identify the cleavage plane. Moreover, this patient had some radiotherapy for breast cancer, so probably cleavage will not be that easy. Once we can find what we want on one side, we will move to the other side.

5. Dissection on left crus 03'07''

This is the left crus. Sometimes it is easier to find the cleavage plane on the left crus, so if you do not find it anteriorly, you can find it at this point.

6. Identification of cleavage plane 03'19''

I think this is the right plane. We are not working at all in the sac, but outside the sac. This is the basic rule for the treatment of this kind of hiatal hernia. If you work inside the sac, you are totally lost and you cannot find your landmarks. This is an avascular plane. Now we will try to reduce a little bit the fat, because the sac is coming out, so it should be more stable. We see the stomach. The problem sometimes is top get a good exposure of the lower part of the crus, if it is grabbing the sac. The crus is there, so I can divide this. This is like an inguinal sac. Always on the left crus, because that is where you have fibrotic attachments. You can feel that things are coming as soon as these attachments are divided. This approach from outside the sac is very important because the important structures like the esophagus are preserved, as they are inside the sac, and normally, when you are getting above the sac, you find the esophagus. The esophagus should probably be somewhere here. We change and continue our mobilization.

7. Dissection towards the right side 04'47''

We are just working around the hiatus. Now we will go on the right side. Once you are in this plane, it is quite easy using blunt dissection. This is the absolute criteria that confirms that you are in the right plane. If it bleeds, you are not in the right position. We can already see that the stomach is now in this position. We did not touch the stomach. As we have reduced the sac, everything is coming down, so we do not have to fight with the stomach to start with the operation, as this is a waste of time. We still have to find the posterior cleavage plane. There is usually a big lipoma at the back. We will progressively try to find the left crus from the back of the esophagus. I am still very cautious because I do not know where is my vagus trunk. If we do not know, we have to go up in the esophagus so that we can find our previous dissection on the left crus from the other side. This is the posterior channel. The vagus trunk is somewhere here.

8. Umbilical tape placement on the GE junction 06'09''

I think that now we have probably reduced the majority of the sac. We will hold the GE junction with the umbilical tape, because it is easier to grab the structures. Probably we are at the level of the GE junction there. To know it exactly, we will have to clear all the sac that is going up to the GE junction.

9. Esophageal mobilization 06'37''

Now I will mobilize a little bit more the esophagus form the mediastinum, because now we have a good traction on it. We need this extensive esophageal mobilization to get the cardia below the diaphragm, so this is a crucial step in this procedure. The length of the esophagus is one of the factors that can explain the recurrence, so there is a rule: we are mobilizing very high in the chest. Now we have cleared the right border. We continue on the left border. The vagus trunk is there, the lung and normally the vagus trunk is going to the left so that’s where usually we stop initially our dissection.

10. Clearing of GE junction and hernia sac reduction 07'29''

So now we’ll clear the GE junction in taking down the sac. This is a very tedious part of the operation. We’re trying to clear the junction as much as possible because if we leave a residual sac, this may be a cause of recurrence and that’s usually linked to the posterior lipoma. So that’s one side. The problem with this surgery is that usually we don’t know what happens with the vagus trunk in this area because it’s probably somewhere in the sac but it’s not a major issue because it’s not a problem with this patient. The important thing is to get the junction and the stomach in the right position. She has a recurrence with a small sliding, which is not a problem. The important thing is to maintain the stomach in the right position.

11. PTFE crura reinforcement 08'49''

So I’m using a little piece of PTFE from the cardiac surgeons that I will place on the crura. That will reinforce our suture in this large hiatal hernia where usually the simple suture is a little bit fragile. We’ll get the junction back. And so you see I’m going through this Teflon pledget. We’ll do on the other side. We are very careful because the vena cava is there and we have a quite nice vein there. So usually the first stitch is the most difficult as we have to control all this fat. So you see that it avoids a cutting effect of the thread, the suture on the muscular bundles. This is our first alternative to a simple suture so when the orifice is large but not extremely distended and we’re using mesh only in very rare circumstances when we can’t close properly the muscles because there is too much distension or no crural muscles any more. It’s more common in redo surgery because usually in large hiatal hernias, we can achieve suture with muscular bundles. So now we’ll check the position of the esophagus in order to avoid too much tilting from the back. The hole is big so probably we’ll need some lateral there. Here I think it’s enough because it’s the normal position of the esophagus so from the back, it’s enough. So I’ll resect this little piece to avoid contact with the posterior esophageal wall. So we know that when we’re doing this sort of surgery, we have to add an antireflux mechanism so in this 71-year-old patient, it’s important to add that because we know that she has a big chance of getting reflux so we’ll do an antireflux repair. We’ll see what sort of reflux repair we’ll do. Probably a partial posterior would be sufficient. It depends on the size of the gastric fundus. I think it’s important when we’re treating very old patients in acute situations sometimes we do not add this antireflux mechanism. We just cure the hiatal hernia but for younger patients, it’s important to add an antireflux mechanism. So this is a summary. First work outside of the sac to reduce the hernia, second is to clear perfectly well the GE junction and the lower esophagus in order to identify exactly where the GE junction is. If the GE junction lies below the diaphragm, it’s OK. If the GE junction is getting back inside the chest, you need to lengthen the esophagus; then the crura repair usually with Teflon pledgets, and then the antireflux repair.

12. Floppy valve creation 12'15''

So now we will move to the gastric fundus and we will mobilize the first attachments in order to have quite a floppy valve. We don’t need a very extensive mobilization but just this part to get a good valve. So we’ll do a short, floppy valve. See it’s not very tight. So now we’ll anchor the valve to the GE junction. It’s just to stabilize the antireflux mechanism in the right position.

13. Vicryl mesh placement 13'14''

Now in order to protect the diaphragm in the early postoperative period, we’re using a Vicryl mesh, absorbable material, with a key hole, some marks, because we use the full-thickness, all layers of this Vicryl mesh. I will put the esophagus in the hole. The idea is to prevent the early diaphragmatic trauma at recovery during the first postoperative period and as we know that the Vicryl will disappear within 3 months, we won’t have the risks or the problems associated with the use of mesh around the GE junction. And of course, it’s like the Vicryl mesh that we’re using for preventing early evisceration after surgery in septic patients, etc. so it’s in the same way. We’re not fixing the mesh because it’s very large. You see that we’re deploying all that on the diaphragm surrounding the esophagus because here we are absolutely secure with the contact of this absorbable material with the esophagus. So you see that’s a good protection of the diaphragm and we’re using that for almost 2 years without any complications.

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