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Leroy J. Giant hiatal hernia: laparoscopic management. Epublication: WeBSurg.com, Nov 2004;4(11). URL: http://www.websurg.com/ref/doi-vd01en1370e.htm

Giant hiatal hernia: laparoscopic management

Add to my favorite list Lien TDM:  Générale et digestive > Estomac et duodénum > Hernie hiatale, reflux > Volumineuses hernies hiatales J Leroy (France) November 2004 English - 09'00''   Regarder la vidéo 00'12''  Trocar placement Today, we’ll be operating a patient with a voluminous hiatal hernia. Our preoperative chest X-ray showed an intragastric gas bubble pneumothorax. Upper GI series was done, which showed a contrast in the chest and an MRI showed anterior lung compression by the hiatal hernia. We use 5 ports. The working ports are in the left and right subcostal positions. We place the camera port mid-way between the umbilicus and the xiphoid and 2 other ports are used for retraction. 00'43''  Hernia reduction The procedure begins with adhesiolysis to free the left lobe of the liver, which is then retracted with an atraumatic liver retractor. At this point, the hernia sac contents are reduced back into the abdominal cavity. We can see that a large portion of the stomach was herniated up into the chest. Once the contents have been reduced and placed under traction, we will begin dissection of the hernia sac away from the hiatus itself in the mediastinum. Here’s a view of the mediastinum inside the hernia sac. 01'30''  Hernia sac reduction into the abdominal cavity Next we have to dissect the sac away from the mediastinum and pull it back into the abdominal cavity. We begin this on the left crus, the superior aspect of the hiatus. We then travel to the right side of the hiatus and you can see below our incision the right crus. Only the peritoneum is divided initially. And you can see the caudate lobe of the liver. Now we have a good exposure of the right crus and we continue dissection in this plane. Pressure of the pneumoperitoneum provides a sot of pneumodissection and we use this to aid in exposure as we continue to take down adhesions between the mediastinum and the hernia sac. Continued intra-abdominal traction is necessary to pull all of the contents back in along with the sac. Now we continue our dissection to free the esophagus as proximal as possible to allow for 2 to 3cm of abdominal length. The use of ultrasonic scissors greatly facilitates this dissection as you can see. There is really almost no bleeding. Here again is the right crus and we will continue to dissect this out inferiorly and posteriorly. Careful dissection of the sac is necessary to prevent pleural injury. However, if the pleura is injured, the case can be continued as long as the anesthesiologist is able to provide positive pressure ventilation with the addition of a small amount of PEEP. 04'15''  Cruroplasty We can now begin to re-approximate the crura using interrupted non-absorbable sutures. We use extracorporeal knots in order to maintain the tension of re-approximation once we have placed the stitch through both the left and right crus seen here. It’s important to catch the peritoneal edge if possible on both sides to reinforce the suture. You can see our extracorporeal knot pushing device. It maintains the tension of closure and the suture is cut. A total of 3 stitches will be placed for the repair. For mobilization of the esophagus and proximal stomach is absolutely mandatory prior to closing the hiatus and ensure intra-abdominal esophageal length. In our team, we use Ethibond to close the hiatus. 05'24''  Fundoplication Once the hiatus is closed, we can create a wrap and in this patient, we will perform a Nissen fundoplication. Our retroesophageal window has already been created as part of the mobilization of the esophagus and pulling the stomach through can be accomplished without difficulty. As you can see, we are able to perform a truly floppy wrap. We are now placing our sutures anteriorly to create the wrap. We use an extracorporeal knot pushing device as seen here. First stitch is stomach to stomach. The 2nd stitch will incorporate a small portion of the anterior surface of the esophagus to fix the position of the wrap. See the small bite of the esophagus just here. It’s essential that the wrap be placed proximally enough, that is around the distal esophagus and not around the cardia of the stomach. The presence of the distal esophagus intra-abdominally allows it to be exposed to the relatively high pressure of the abdomen compared to the thorax. 06'42''  Mesh reinforcement A Nissen wrap was deemed necessary in this patient secondary to the high incidence of reflux in patients who undergo hiatal hernia who do not receive an antireflux procedure. We now dissect the triangular ligament in order to create a space for the mesh. We have used a non-absorbable polypropylene mesh to reinforce our crural repair. It was felt that this was necessary given the size of the hernia. First step is to place the mesh around the esophagus. We then position it like so and anchor it using a spiral tacking device as shown here.Once this is finished, the repair is complete. If any spots are found in the mesh to wrinkle, they can be reinforced and closed with the stitch as shown here. This provides a smooth surface and the procedure is complete.

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Générale et digestive > Estomac et duodénum > Hernie hiatale, reflux > Volumineuses hernies hiatales

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