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English - 20'00''
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January 2009
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The laparoscopic approach is considered the technique of choice for the repair of large hiatal hernia leading to low morbidity and mortality rates.
We describe our approach for the laparoscopic repair of giant hiatus hernia. This entails full dissection of the hernia sac from the mediastinum, hiatal repair and the construction of a fundoplication.
| 00'17'' | Clinical case presentation
This patient complained for a long time of dyspnea and shortness of breath. She also underwent a cardiological examination that demonstrated that chest pain was not of cardiac origin and she also presented with chronic anemia. The endoscopy confirmed a giant hiatal hernia; here you have the barium swallow that shows quite clearly the importance of this hiatal hernia. There is also a suspicion of short esophagus; this will be confirmed during the operation. The manometry shows that the progression of the esophageal contraction is quite normal until the contraction reaches the hiatal hernia and you will see here also the length of the stomach in the thorax. |
| 01'10'' | Exploratory laparoscopy and trocar placement
We are checking the peritoneal cavity. This woman had a previous appendectomy so nothing in the upper abdomen. As usual, I put my trocar some centimetres above the umbilicus. Basically, the port placement is the same as for a simple reflux.
I have put my trocar on the left side, this is the one that will be used by the assistant. I am choosing the right place for my left hand. You see that I am always checking the entrance of my trocars within the peritoneal cavity. It is very important to follow the tip of the trocar to be sure that you don’t injure anything; that is the basic rule for laparoscopic surgery. We then move to the right side of the patient, I check the position of the ribs and my assistant will introduce a 5mm trocar. This is for the liver retractor. We will discover with you the hiatus. There is a good part of the stomach within this huge hiatus, probably two thirds of the stomach within the chest. These stomachs are always very long, they are almost like spaghetti stomachs. This is the pylorus, the gallbladder is normal, all the antrum, so probably the majority of the body of the stomach and the fundus are within the mediastinum. You see there is a big cavity, which in fact is the reflection of all the attachments of the diaphragm of the GE junction. Everything is going up, phrenoesophageal ligament, everything is going up and that creates a sac within the mediastinum. This sac comes if I place some traction on it but the stomach goes back immediately. |
| 03'32'' | Sac dissection
What we will do is work outside of the sac to try and find a cleavage plane between the sac and the mediastinal structure. If you go straight within the sac, you don’t know where the esophagus is, you don’t know the structures, but if you come from outside the sac, then you can identify these different structures. You see this is the lesser omentum, we have probably one artery there. We will work by trying to reproduce the different steps of usual access to the mediastinum. I am starting like a reflux operation by opening the omentum, this is the pars flaccida because all the pars condensa has been a little bit reduced there but not enough so initially I want to identify all the important structures. There has always been a lot of discussion around this big left hepatic artery, very few reports of complications but some with left hepatic ischemia and I remember one surgeon reporting the need for hepatectomy afterwards, so initially I try to preserve it as much as possible. Just with traction on the content of the sac, I can see my cleavage plane here. The pleura is also coming so I know that I have to work here. This is the limit of the sac, and again I will try to find my cleavage plane, mostly using blunt dissection. You see this is probably the sac, when putting traction on these structures you can come with the pleura so I prefer to look first, but I think there I am in the right plane. The pleura is there so I’m in the right plane. If you are in the right plane, you don’t get any blood basically.
It is important to work on the left crus before trying to reduce the sac totally. This part is usually a good fixation of the hernia. Again, you see a lot of traction on the different structures to present the different cleavage planes. I am still in the right plane. We are in a quite well-known environment with the aorta there, because we are outside of the sac, so the esophagus probably goes there and it’s easy to find the usual structures. Can you pinpoint the aorta for us? Sure, it is not that far so it’s quite a dangerous area. Now we have done almost all the circumference of the sac, maybe a little bit more on the posterior right side. A big part of this operation is mobilizing all these mediastinal structures. The posterior vagus trunk is there. You see that with a nice preserved view it is not that difficult. This is my left crus, it looks in a reasonable order. Looking like a little bit of a short esophagus but it could be a challenge to get it down I think. Now because I want to see a little bit more, we will work a little bit on the sac because maybe my junction is there now, I don’t know. The sac is inserted there, maybe my assistant could show me where the junction is. He is showing the Z line, so usually it is there. You see the print of my grasper on the Z line, so I will put a stitch on the Z line as a landmark. |
| 09'52'' | Endoscopic identification of the Z line
This is the endoscopic junction. Again with the idea of a different disease than the GERD, I think it is important to have an idea of the exact position of the endoscopic junction; usually my anatomical junction should be probably 1cm below that. You see it is without any traction on the junction. Then we start the real tedious part of the operation. These instruments like the Ligasure or the Harmonic system are very nice because usually beforehand when we had to do that with scissors, it was really awful because it would bleed all the time. Other interesting thing is that these large spaces you leave in the thorax never really cause any trouble. I remember one of my patients in which we got some oozing within the mediastinum and she developed a big hematoma with compression of the esophagus. This woman had quite severe dysphagia for two or three months, and I checked her progressively just to see the resolution of this big hematoma, so that’s really the only patient in which I remember having problems with these big cavities, but usually we don’t use any drainage or anything like that. I don’t know what you do if you use drainage or not. No, I don’t. I have to say that after this experience I would leave a little drain for the first 24 hours, an aspiration drain (Redon) till the next morning. In fact, I don’t know where my vagus trunk is here but I am not anxious because the goal is to release this sac. You see that the endoscopic junction is staying below the diaphragm, so the anatomical junction is there, the endoscopic junction is there, so I have a good length. The goal is not to treat GERD, for that my valve should be in this area. For this sort of intrathoracic stomach, |
| 13'40'' | Crura closure
I think I will probably add some anti-reflux mechanism here, very importantly I will try to close the crura. I will use this Teflon patch from the cardiac surgeons. It is probably one and a half inch long and half an inch wide. You are going to put this on the lateral outside aspect of the crus to reinforce it. I like this because I have the feeling that you can tie it quite well, I prefer that to using a mesh because here I still have some muscle. With this system, we don’t have any contact between the material and the esophagus, so that is my main goal. The only thing that changes in this technique is that he is not using that any longer when creating the fundoplication, he is not using that between the fundoplication and the esophagus because he has got some migration, but he is still using that outside of the valve without any problems so I like this system. It is my standard closure as well. I do horizontal mattresses with the pledgets out to the side like that. I am trying to catch some peritoneum, see the structure is quite nice in this muscle, seems they have a good muscle, which is unusual. The addition of little things is what takes time, like the crura repair, dissection into the mediastinum, the esophageal mobilization and all that takes time, but I think they are important in terms of the result. There is no room for haste in this sort of surgery of the hiatus. Of course, here you can use extracorporeal stitching if you want, some people prefer that. If you look at the thing we are doing now, it is easier to imagine putting a large mesh and tackers that you can do in 5 minutes. But you have to look at the final result. When discussing this problem with other surgeons, it is amazing to see that surgeons who have a very large experience with this area are not very confident in using a mesh, probably because they have seen some problems and complications. Complications of mesh are devastating. Problems can occur and you have to be aware that you are treating benign diseases and ending with esophagectomy that is really catastrophic. When you fix it, because you did a good repair and it breaks down and you have to do something different. Just to avoid this little corner of the pledgets, to fix it a little bit. Any erosion from the pledgets? Never. Now what we are going to do is place the posterior valve there, which will cover the back of the esophagus, usually we wouldn’t have any contact between the pledgets and the posterior cardia. To do a fundoplication, again we will mobilize the upper part of the gastric fundus. This is a PTFE. I think it is probably a polypropylene or maybe PTFE, but not in this texture. It is really the upper part of the stomach, just look at the stomach, it is all intact, and it is really the upper fundus that we are mobilizing, you see we are starting there so it is a little part of the stomach. Lee Swanström would probably do a total, because we have a lot of gastric fundus. You see the vessels there. |
| 20'32'' | Fundoplication
The anti-reflux mechanism is not very important in this patient because they usually don’t have that much reflux, but as we have taken down the cardia below the diaphragm, we have probably destroyed part of the anti-reflux mechanism. We feel it is better to try as much as possible to have some anti-reflux mechanisms. You see the mark is there, so we are folding the mark. See my grasper is around 2cm, so it’s just about the length of my grasper. Usually it is 2-3 stitches, you have to make it very short, that is very important. Some people just use one stitch. Now you see that the valve is quite floppy and I’ll fix the valve on to the esophagus. I am trying to find a stronger part on which to fix my valve. We did a gastric mobilisation and just the upper part of the gastric fundus, we did a floppy Nissen because we have a good floppy fundus and this is the final result with this fundoplication. We fix this valve to the side of the esophagus, on both the superior and the lower part. I think that I will probably try to remove my mark. The question from the audience was do I fix the valve on the diaphragm, and I said that usually no, but in some conditions in which you want to cover more the mesh or the material, then you can fix it a little bit on the diaphragm. But there is no evident data saying that it is better or not. |
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