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Vidéos chirurgicales sur WeBSurg
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English - 14'00''
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Hiatal hernia is a common disorder of the digestive tract. Most patients are elderly and with significant co-morbidities. Historically, the surgical repair of paraesophageal hernias (PHH) has been advocated regardless of the presence of symptoms. In fact, despite patients being symptom-free, the development of potentially life-threatening complications such as obstruction, acute dilatation, perforation, or bleeding of the stomach mucosa, is well-known and has proven to be fatal in 27% of cases. Nevertheless, patients with asymptomatic PHH are likely to develop symptoms needing emergency surgery in only 1.16% of cases with a 5.4% mortality rate. Recently, several authors have questioned the indication for repair in asymptomatic patients and prefer to monitor asymptomatic or minimally symptomatic PHH by ‘watchful waiting’. Our current practice is to operate only in the case symptoms or complications. The laparoscopic repair of PHH is certainly technically challenging. It requires considerable experience with minimally invasive surgery of the foregut, and a complete understanding of esophageal pathophysiology. The basic principles of surgical repair are the reduction of herniated stomach and distal esophagus into the abdominal cavity with tension-free repositioning of 2cm of lower esophagus in a subphrenic position, complete excision of the peritoneal hernia sac from the mediastinum and the repair of the diaphragmatic hiatus.
This is the case of a woman admitted to the emergency room for complete acute dysphagia associated with type IV paraesophageal hernia. The preoperative work-up (CT-scan, upper GI series) showed the migration of the stomach, left transverse colon and omentum into the chest.
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| 00'06'' | Clinical case presentation
A gastric volvulus on the occasion of a giant hiatal hernia is quite an unusual occurrence. Previously, the risk associated with this would be an indication for surgery, even if asymptomatic. Nowadays, we know that only hiatal hernias with symptoms need to be operated upon. This patient has a complete acute dysphagia and the exploration of the hiatal region allows us to ascertain that the whole of the stomach’s upper portion is incarcerated. There is also a partial herniation of the left transverse colon and omentum. |
| 00'55'' | Reduction of the sac contents
Reducing the colon and omentum herniations usually cause no problems, but in these acute situations, a reduction of the stomach from inside the hernia sac is deceptive, so that we need to observe the recommended technique: the approach to the volvulated stomach is not done from inside the hernia sac, but by splitting the mediastinal space between the hernia sac and the mediastinal structures. This is the only way to avoid visceral lesions when reducing these types of volvuli and getting landmarks in the mediastinum.
This patient has an important stomach deformation as it is located in the right side of the thorax, and at this level, it can be seen that there is a dense cleavage plane between the mediastinal structures and the hernia sac, especially with regards to the adhesions with the right pleura. Once the cleavage plane has been identified, the procedure will consist in freeing this cleavage plane around the hiatal orifice from right to left.
Some surgeons consider that the cleavage should begin when in contact to the left crus, which is a perfectly valid technique; it just depends on the surgeon’s habits. However, the phrenoesophageal membrane’s fixation at the level of the lower portion of the left crus must be freed, as it is usually from there that the most important fixations of the sac are observed. Here we notice that the hernia sac is extremely inflammatory, the pleural adhesions are very tight, further demonstrating the acuteness of the phenomenon.
The idea of performing an extra-saccular approach is important as not only does it allow to reduce all of the herniation, but it also provides a quick access to the mediastinal structures such as the esophagus, thus avoiding lesions due to wrong angles or a bad cleavage plane. The hernia sac is gradually reduced below the diaphragm. |
| 04'09'' | Excision of the sac
In this patient, the hernia sac is very large so that to complete the reduction, we will incise and divide the hernia sac. The stomach’s reduction then becomes possible, and on it we can notice the effects that the volvulus has had: small lesions of venous stasis at the level of the gastric fundus wall. Here we notice a strangulation phenomenon at the level of the hernia sac; in order to complete the sac’s reduction, we will open, divide and free it from its insertion at the level of the cardio-esophageal junction.
Here we see the completion of the sac’s reduction as we manage to gradually identify the muscular structures of the diaphragmatic hiatus, especially with the top of the sac that has been reduced. The left pillar is identified.
All this allows for the retro-esophageal passage of a forceps and the introduction of a retraction loop that will position the cardio-esophageal junction and provide directions for the next dissections. At this point of the procedure, we return to a standard treatment of giant hiatal hernias. |
| 06'39'' | Intramediastinal dissection
The first two stages are reduction and excision of the sac along with identification of the cardio-esophageal junction. The traction applied on the loop situated at the level of the cardio-esophageal junction is important as it allows to extend the intramediastinal dissection in order to obtain a segment of distal esophagus located under the diaphragm. This is one of the parameters that prevents secondary herniations. The intramediastinal dissection is performed from top to bottom, usually starting on the right and going to the left. The different structures, especially the posterior vagus nerves, should be identified at this level. Pleural lesions should be avoided as much as possible, even though they do not have any major consequences anesthesiologically. At the level of the left esophagus, there again the mobilization must preserve the anterior vagus nerve, and we can see that some very tight adhesions are being freed. Again, the pleura’s preservation is an important parameter. |
| 08'19'' | Reconstruction of the diaphragmatic orifice
The reconstruction of the diaphragmatic orifice is the next step of this type of hernia repair. The different options are not discussed in this video, but in this patient, the crura’s muscular structure appears to be satisfying, so that rather then considering a prosthetic repair and the risks that come with it, we decide to perform a reinforced cruroplasty using Teflon pledgets. These pledgets are used in heart surgery and they can be applied nicely to the muscular structures of the crura. This repair begins in a retro-esophageal fashion, at the level of the junction between the two muscle fascicles of the right and left crura, and by progressing to the posterior surface of the esophagus. Depending on the orifice and the direction of the esophagus, the closure will eventually combine anterior and posterior stitches. Indeed, significant angulations of the esophagus must be avoided as much as possible. The advantage of this type of reinforced repair is that there is hardly any contact with the esophagus and we can see here that the crural orifice is further reduced by the application of this lateral stitch. At this moment, the procedure could be stopped as hiatal hernia’s reduction has been completed. However, in order to further stabilize the cardio-esophageal junction in the peritoneal cavity, we decide to perform a partial posterior fundoplication. |
| 11'20'' | Partial posterior fundoplication
This partial posterior fundoplication is fixed to the right and left lateral borders of the esophagus. It is also fixed at the level of the diaphragmatic crura: this further stabilizes all the different elements and should theoretically diminish the risks of re-herniation. Another advantage of this type of anti-reflux wrap is that it prevents the return of gastroesophageal reflux syndromes that can be linked to the restoration of the gastroesophageal junction’s anatomy in the context of a voluminous hiatal hernia. |
| 12'58'' | Postoperative period
Following the procedure, the patient is allowed to drink on the night of the procedure. On postoperative day one, we perform a water-soluble contrast examination.
In this patient, the exam shows the correct repositioning of the cardio-esophageal junction under the diaphragm, the absence of stenosis. In this volvulus case, we prefer to leave an intra-mediastinal drain during the first 24 hours in order to prevent any residual hematomas in the mediastinum. |
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