00'20''	Patient position and exposure The patient is placed in a lithotomy position and the surgeon stands between the legs. One assistant is standing on each side of the patient. The trocars are inserted as shown here. An extra trocar can be inserted for difficult dissections. I’m coming with this instrument, which is the Ultracision system that I like in this type of hernia, because usually there’s bleeding. These are the hepatic branches of the vagus trunk. Usually in a normal hiatal hernia, I keep these but for this huge hernia, I must admit that I divide them. Now I’m trying to open the lesser omentum. My first goal is to get access to the crura and you can see the crura there. I’ll try as much as possible to work outside of the sac. This is the crus.
02'04''	Dissection of hernia sac I’m trying to find the plane between the crus and the sac. It’s very important to find the right plane outside of the sac. This is the key to this operation. I’m working around the hiatal orifice. The problem is that at this point you don’t know anything about the position of the different structures like stomach, esophagus so you have to be very careful. This is the crus. The problem is the pleura. So we made the circumference of the anterior part of the hiatus. This is the sac and we’re going to work deeper in this sac. This is probably the top of the sac here. You see a lot of blunt dissection is used here. You can use different types of coagulation. It’d be interesting to retract this probe and show exactly where the esophagus is. The esophagus is there. The probe is down on the cardia. I think it’d be interesting to have the probe there. We progressively retract the sac and as soon as you find a good plane, it’s easy to find the esophagus. So the probe is helpful but not crucial. We’ll continue on the anterior part of the sac. I’m still trying to prepare the gastroesophageal junction, trying to find a plane between the sac and the esophagus. I’m now trying to find the crura posteriorly and I think they are there. You see that because I’ve prepared the left crus at the beginning of the operation, it’s very easy to find a plane behind the esophagus. Now I’ll introduce an umbilical tape. Now we try to retract this sac. It’s sometimes difficult. If the sac is too big, I’ll resect it. I like to have a junction that is clear. Most of the time I keep it, because if you need it, you can use it to cover some mesh. The junction is coming down progressively. The sac is still in this area so probably I’ll clear it a bit. But first I will clean everything down there to get the esophagus back. So the GE junction should be somewhere here. This sac is a problem if I want to do a wrap so I clear it. You see the plane we have to clean to mobilize the esophagus a bit more and then we can close the crura. It’s true that it’s difficult to know exactly where the junction is. No probe within the aorta. I’m just trying to get half a centimetre more. It’s mostly a blunt dissection. I don’t like to use a hook within the mediastinum. Probably the junction is there. We’re going to close the crura now. I think the length is quite good; if we release the traction here, it doesn’t go back. We’re going to close this hiatus and we’ll fix the probe to the crura.
09'06''	Closure of hiatus To do a very good bite, in laparoscopy, the size of things is different than in reality, be careful here because there is the vena cava, so it’s not good to take the probe into the vena cava. So here you see the direction of the esophagus is quite nice with a posterior stitch.
10'34''	Resection of hernia sac We’re cleaning a bit this junction. I like to have this part down because that would be inside of the valve, which is not very good. So you can see that I’m just trying to put the anatomy correctly. So the next step is to prepare the stomach for the plication. So this is the rear cavity. These are the posterior attachments of the fundus. We just check if there is no bleeding and then we’ll do the valve.
13'38''	Fundoplication Now you place your 1st stitch, you can appreciate the shape of the valve, no torsion. Then you place the other stitch and you fix it on the esophagus. You must make sure that your 1st stitch is not tightening the esophagus.

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Bernard Dallemagne

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

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