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Swanström LL. Laparoscopic treatment of hiatal hernia. Epublication: WeBSurg.com, May 2005;5(5). URL: http://www.websurg.com/ref/doi-vd01en1779e.htm

Laparoscopic treatment of hiatal hernia

Add to my favorite list TOC link:  General and digestive > Stomach and duodenum > Hiatal hernia, reflux > Giant hiatal hernias LL Swanström (United States) May 2005 English - 20'00''   Play video 00'09''  Trocar placement Everybody does trocars slightly different but for fundoplications, having it high in the abdomen, it is critical. Here’s the umbilicus and the xiphoid is there and I think it should always be at the midpoint or higher. Do you change the position of the trocars with regards to the xiphoid process when you’re doing a male patient or female patient case? A little less male and female but according to their weight, very obese patients have a large liver and so we move trocars further to the left because there’s more room and somewhat males have more intra-abdominal fat as well also so I tend to migrate things slightly to the left. I like to put my trocar off the midline just because the esophagus comes in right to left and it lines up nicely; one of the key lessons of laparoscopy of course is to have the camera between your right and left hand so these are the ports I’ll use. My assistant has the liver retractor over and far subcostal. 01'19''  Opening the pars flaccida Today I’m going to use the Ultracision but this is a little bit faster and sometimes I use monopolar scissors, sometimes Ultracision for the whole case. I see that you’re dividing the lesser omentum from the lower part up to the hiatus. Do you have the feeling that dividing the vagal branches has an influence on the long-term outcome of the patient? Because I’m trying to preserve those branches in all the patients and then I don’t know if I’m doing it for nothing or if it can have some long-term influence. The evidence is slim. As a purist, you may want to keep them because they are there for a purpose. Well, as you demonstrated it’s a controversy always. For a long time, I saved it and I never saw much of an advantage, it still had the occasional cholecystitis or gallstone, but I don’t know what the answer is. 02'40''  Crura dissection I find it hard to retract and not lose it. You’re using ultrasound dissection and we see the blade anteriorly, is there any reason for it? The bottom blade is inactive, no damage, the upper blade is active and so it can damage so I like to always visualize the active blade so if I was cutting down here I can’t see where I’m cutting. Like this, I can see the active blade. So it’s a safety technique for protection purposes. The blade is active anterior and posterior. I’m back to those fibers. I just want to recommend to the people who are starting with this type of operation to divide this bridge because it opens widely the hiatal area and afterwards when you get used to this dissection then you may try to preserve these branches. At the beginning, it clarifies the hiatus. When you have a big vessel, to preserve that is most important. It’s also important to clear the right crus quite low. Now you can see the right crus coming in right there. Actually let’s take this down a little bit lower. It’s very important to keep the peritoneal covering on the crura and it’s difficult to do but here it’s the peritoneum, this white line is the peritoneum covering the left crus and so it stays wide. It’s tempting to go in right there but you end up stripping the peritoneum off the crus. I’m doing things differently here from this step onwards. I’m working on the left crus from above to clear it and then it’s a little bit easier to find this posterior channel if the crus is already prepared on the other side. That’s a crucial step of the operation because we know that all the accidents and damage are coming from this step. You can’t do anything without getting a good view. Some people are doing it blindly with curved instruments and we know that half of the time you’ll go directly into the back of the esophagus, particularly also in obese patients. 06'20''  Mediastinum dissection Having an angled laparoscope helps to get a good view and I also like to identify the anterior vagus early. It’s then easier to identify in the mediastinum. Here’s the vagus right there. So I identify that and then I move down into the abdomen with that under direct view. We are working from the preoperative clinical data to choose between the partial and the total valve. Occasionally I still do a partial fundoplication but it’s unusual that you need to do one I think. I do probably one partial a year. Sometimes we have patients with a gastric fundus that are not suitable for a total valve. Very small gastric fundus even with a good mobilization of the gastric fundus, you can’t do a proper total fundoplication. So I’m doing a partial one in such conditions. How about for very severe motility disorders? The patient has scleroderma. Lots of these dysmotility problems seem to be secondary to the reflux so correct the reflux and the motility. It’s better. One of the criteria of the manometry is to look at the esophageal wall. If you have motility disorders in the upper third of the esophagus, then you have to be careful. If you have motility disorders in the lower third, it’s a 100 percent related to the severity of the disease. If you have motility disorders in the other part of the esophagus, then you need to be careful because it might be another disease. The patient has a little bit of a short esophagus, not terrible but I did go quite far up in the mediastinum to mobilize it. You can show how far up you can get, maybe 4 or 5cm up inside the mediastinum. And if you need to, you can go much further than that. Do you ever use a fat stitch to hold the omentum down around the spleen? I don’t usually do that, it’s pretty easy just to manipulate it out; on occasion I had an extra port and somebody can just retract it down. You don’t add an extra port to put it outside one of your existing ports and put a stitch into the omentum and pull it down? I know it’s a good trick. The crucial point about this operation is to have landmarks, which are the crura. 09'59''  Fundus mobilization As soon as you have identified the right crus, you know that the esophagus is round there. If you don’t find that, you have to stop the procedure because we have seen videos where the surgeon is dissecting the vena cava. I know 2 cases in Oregon, they misidentified the vena cava as the esophagus and tried to do the fundoplication around the vena cava. What is your limit for your gastric mobilization? I like to do the upper third of the fundus as you discuss the lipoma, the fat on the greater curvature, I use that as a landmark, which is about the lower pole of the spleen. What about preoperative barium swallows, do you do that as a routine or? Not as a routine to map out a hiatal hernia if I need some anatomy knowledge, we do pH motility on everyone preoperatively. It just serves as a good baseline to follow all the patients up postoperatively if they have any problems. There’s been a paper on that comparing pH monitoring with the PPI test if I have a patient with esophagitis or typical symptoms responding to PPI. If there’s a patient who does have problems after surgery, it’s nice to know what they started with as far as their pH test. In terms of postoperative evaluation, you’re right. It’s better. But the problem is that in some patients, manometry and 24 hour conventional pH monitoring is not the perfect test. I’m using more and more the Bravo system, which is the 48 hour monitoring with the capsula into the esophagus. I’m using that for extra-esophageal symptoms. I believe that and I have made some comparisons between the usual pH monitoring and the Bravo system and we have patients with a normal pH monitoring and we did a Bravo and the Bravo was positive so I don’t think that based on a normal pH monitoring in a patient with typical symptoms responding to PPI there’s a question. If you are logical, you can’t do surgery because you have no proven reflux. Have you been using impedance pH? That’s been a good test for those patients you described with normal acid pH. You need to absolutely beware any patient who does not get good response from PPI, that’s the dangerous group, if you operate on those, you’ll have an unpleasant time because they’re not going to do well. 13'28''  Positioning the valve Perhaps you can divide the short gastrics, not dividing the posterior fixation of the fundus to the diaphragm as we have seen. You have freed the fundus completely. Is it always necessary to divide the short gastrics and posterior attachments? The general thought is that actually it’s more important to free the back attachments than it is the short gastrics because we use the greater curvature for the wrap. So but it’s actually a good question particularly if you’re doing the Rossetti type, then it’s probably not so necessary. Because if you keep the fixation, it’s impossible to do a perfect fixation between the posterior aspect of the fundus and the anterior aspect of the fundus. It’s what Dr. Dallemagne recommends. It’s only to extend what you did since it’s important to see that it’s not only the division of the short gastrics vessels you did to have an easy and a floppy valve probably. I believe so. Is it not a danger for postoperative migration? Possibly if you over-mobilize, same criticism with mobilizing in the mediastinum, it means you have to be very careful with how you close and that’s one of the reasons I had the extra sutures. 15'00''  Hiatoplasty There’s the nasogastric tube right now. It’s a nice way to look at the fundoplication from the inside to look at the valve and I find it very useful learning because sometimes it looks perfect on the outside and on the inside it’s not so good. There can be a twist. Most of the time, I feel concerned about the length of the esophagus. I’d love to do my own endoscopy so I’d do it probably in half of the patients just to be sure that I have localized the Z-line well. This step of the operation is a difficult one for me. I think that’s true. That’s very deceptive where the Z-line is. This is a perfect technique for suturing. We have seen how to do a knot, when you lock it, you can unlock it. I think it’s important to test the patient before surgery, and especially the response to PPI. I’m used to testing the patient with a normal dose and if there are still symptoms that I don’t understand, I’m increasing the dose so I have some patients who have more than 100mg of PPI a day for 1, 2 or 3 weeks and I’m testing the response to PPI. If I don’t understand, then I’m switching to something more sophisticated like the Bravo system or the bilimetry. But as for the PPI test, you don’t need big instruments to do that. So just increase the dose and if the patient is not asymptomatic with the drugs, you have to look for something else. At this point in the operation, do you think that it’s important to make sure the stitches are in the right crus and not postage stamping, in other words, they‘re not all in the same lines so you get tearing of the muscle? Yes that’s a good technical point because of the 2 technical points of closing is to keep the peritoneal covering on and you noticed I kept enough so that I could wrap it around and get 2 bites of the peritoneum. And the other one is as you say not lining the sutures up in the same line. This is a very good trick to do so there’s a square knot and if you pull on these 2 strands, it will convert it to a slip knot and then as long as you keep straight pressure, you can slide that knot very easily. Do you have any criteria in mind about the necessity or not to perform any reinforcement of the crura repair? Is it the aspect of the muscle or the size? Do you have any tricks to appreciate that? I think the degree of tension you can feel, if it’s a lot of tension, if you start seeing tearing of the sutures, the crus starts tearing and here the knot is a bad sign and every time it’s a redo where the fault was the sutures tore out, then I think you absolutely have to reinforce. The esophagus in this patient was a little bit short so I’m going to do a trick that I do when I’m a little bit worried, that it’s under a little bit of tension, I add extra sutures on the inside of the wrap. I tend to avoid the slippage. The posterior part of the wrap is very loose when you take down a laparoscopic Nissen, there’s not much fixation posterior. If one vagal trunk for example is cut, what are the sequels postoperatively? I think physiologically, there’s no consequence to losing one vagus. 19'40''  Fundoplication I think that cutting even 2 vaguses, I know one esophageal surgeon in my area routinely when he has a short esophagus divides both vagus trunks. It’s a functional disease so we have to be as functional as possible so we have to preserve as much as possible. What about the side effects of floppy Nissens in division of the short gastrics as compared to the Nissen-Rossetti procedure (mobilization versus no mobilization) in terms of postoperative bloating? Possibly it’s true. I like to have a lot of fixation so each of my Nissen sutures includes a bite of the esophagus. I don’t know if that’s necessary or not but it’s easy to do. And you do everything you can to stop them from recurring and then if you have to do it, it makes it worse. You’re taking quite big bites of the stomach there. I take full-thickness bites. I don’t worry much about that. I’ve never seen a problem. I’m more conservative on the esophageal bite. Do you sometimes use drainage at the end of the operation? Not in a routine Nissen but in a re-operative Nissen, we found that measuring the millilitres in the Jackson-Pratt drain is much more sensitive than a gastrograffin swallow so I often leave a drain if it’s a redo case or a very complicated myotomy and then the one thing that’s different is in giant peri-esophageal hernia, I put a drain in the mediastinum because you get a seroma there and it is disturbing to the patient. We’re all done. I thought there was a little tension here so I wanted to take an extra short gastric but. The patient who is still dysphagic, I’d significantly say without much change from the time of the operation to let’s say 5 weeks later, what would be your management to such a patient? First I’d try an empiric dilatation. I think they usually respond one or 2 dilatations maybe 57 French. I’d first do a swallow just to make sure there was not some gross mechanical problem like a herniation of the fundoplication so I do a gastrograffin swallow to rule that out but then I’d do an endoscopy, my own one and do a savoury-type dilatation and 85% of the time that’s going to fix it, very reluctant to take them back and convert them to a partial fundoplication and would wait at least 6 months at a minimum.

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General and digestive > Stomach and duodenum > Hiatal hernia, reflux > Giant hiatal hernias

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