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Dallemagne B. Laparoscopic treatment of a recurrent paraesophageal hiatal hernia. Epublication: WeBSurg.com, Apr 2005;5(4). URL: http://www.websurg.com/ref/doi-vd01en1783e.htm

Laparoscopic treatment of a recurrent paraesophageal hiatal hernia

Ajouter à mes favoris Lien TDM:  Générale et digestive > Estomac et duodénum > Hernie hiatale, reflux > Volumineuses hernies hiatales B Dallemagne (France) April 2005 English - 20'00''   Regarder la vidéo   Add comments 00'18''  Case presentation There are no adhesions at all in the abdominal cavity, which means that the surgeon knew about the anatomy and the different dissection planes, because he was not looking in each direction. You see we have part of the stomach that has herniated into the chest so here we have no problems; sometimes problems can come from adhesions within the chest and mostly adhesions to the pleura. We are going to reduce this herniation and then restore the fundoplication within the abdominal cavity, and then we are going to check the quality of the anti-reflux repair to see if we have to change something or not. The very important landmark here is the right crus. We will divide these small adhesions there just to clear the field and then work into the mediastinum. I am using scissors with monopolar coagulation. These make it easier than an Ultracision system because they are more precise. We can find some stitches. 01'42''  Dissection of hernia sac Now I am working only on what I can see has been done with the sutures. The main difficulty initially is to avoid bleeding and finding the GE junction and the esophagus. I am working outside the mechanism. I don’t know if the previous surgeon is used to fixing the valve to the crura. Those sutures don’t look like the fundoplication suture, they look like sutures to the crus? Yes, that is right. I think that the crus is there. As soon as I have been on one area, I move to the other one to have a general view of the structures. We don’t have to be stay on one side but really to move from one to the other to find the opening. It is very important to get a perfect view of the different planes so the camera needs to be perfectly well focused. This patient operated on in 1994 has got a real Nissen with freeing of the greater curvature and 4 stitches placed, none taking the left or the right crus, there are only 4 stitches on the wrap. In 1994, there were no ligating systems, it was a time when we were used to putting clips. We are trying to find the position of the esophagus. That looks like still stomach? Yes. The colors are very important, there is another clip there. In 1994, we always controlled the short gastric vessels with clips, that is a clip of the short gastrics. I think this is the greater curvature, so I can go through this. I try to preserve the pleura, but usually it is not a problem if you make an opening on the pleura, you just have to call the anesthesiologist and tell him that he has to adapt the PEEP a little bit and the ventilation rate. The problem with this paraesophageal herniation is that usually the esophagus lifts in a position that you don’t know exactly at the beginning. That is why you have to be very careful not to go straight ahead. Might be stomach and that might be the valve and the esophagus might lie down there so that’s the reason why I am very cautious. When you have a very large herniation, it’s almost impossible to keep the hepatic branches. It is a landmark of the cardia. If we do the valve above it, normally we are on the esophagus. That might be the valve. The esophagus should be somewhere here, these are muscles. The adhesions into the mediastinum after laparoscopic surgery can be very hard and even harder than after open surgery. I feel it’s important to have an X-ray of the mechanism after the surgery, because if something happens with the variable delays of the operation, you always have something to compare to. You can see a lot of things with X-rays. With endoscopy, it is sometimes very difficult to understand what they describe. Sometimes I also go the endoscopy room and look with the gastroenterologist to understand better. They are moving the nasogastric tube here, so I think the esophagus is there. This is part of the fundoplication, the other part is there. We grab cautiously the fundoplication and I try to reduce this. On this part, there are usually quite strong adhesions with the fundoplication but it’s ok even if you do a small hole, it doesn’t lead to too many problems. It’s true that here you should have some crura repair and it is sometimes difficult to find the right plane, it’s in this area that you make some perforation. I am looking for the lower part of the crus, I can then find my way. You see how the valve develops in the chest, it is huge. I would like to go on the left crus there; the crucial part is to find the attachment on the posterior left crus; if I find that, I can pass behind the valve and I’m done. I cannot leave a valve like this because it is huge. We will dismantle the valve. 11'05''  Freeing of the wrap I think that the valve is fixed on the esophagus so I try to find the right plane because it is also an area. The esophagus is there, so the plane is there. There should be some stitches on the esophagus there. Posterior vagus trunk. 12'18''  Freeing of the esophagogastric junction So when you look at that, we have the feeling that the junction is coming back into the abdomen, in fact everything herniates like this. 12'42''  Freeing of the posterior wall of the wrap I am using the Ultracision there because there are some adhesions. I want to pass this valve behind the esophagus, close the hiatus and recreate a fundoplication because the length of the esophagus is good. We have prepared some Teflon patches for the hiatal closure and some Gore-Tex reinforcements if needed. 13'30''  Hiatoplasty These are probably some remnants of the gastric mobilisation. We dismantle the fundoplication, the length of the esophagus is good. When we were dissecting, we just saw the anterior vagus trunk. We are moving to the crura repair and I will prepare my little piece of Teflon. I am using the Teflon pledgets, you can transfix them easier than the Gore-Tex ones with a normal needle. Teflon is always very difficult to fix and even in open surgery, it’s always difficult to transfix that. We have the feeling that we have reinforced something so this can be helpful for the patient. My first feeling when we look at the result is that we have quite a high recurrence rate. If you have a recurrence after redo for this type of intra-thoracic migration, then I would probably do a Collis Nissen lengthening procedure and a mesh. I am sure that the intra-thoracic migration came very early and the symptoms came after because of the development of the valve within the chest. But the valve was still good in terms of control. When they get dilated like that they trap air and it causes a problem. They do thoracic bloating. I think it’s quite comfortable for the esophagus here, we don’t have direct contact between the esophagus and the mesh because we have these muscles there so I think that should be OK. That should be the anterior wall here, the anterior gastric fundus is posterior. I thought I would have more problems with the size of the gastric fundus but it comes quite well. 17'38''  Redo fundoplication Without crura repair, this patient would have had the wrap in his chest the day after the operation. That’s the reason why I am still using this graphin swallow because it’s very easy to replace a fundoplication on the first day compared to if we do it some years afterwards. Comments on this media No comments.

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