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Leroy J. Large hiatal hernia: laparoscopic Toupet procedure. Epublication: WeBSurg.com, Sept 2004;4(9). URL: http://www.websurg.com/ref/doi-vd01en0038e.htm

Large hiatal hernia: laparoscopic Toupet procedure

Add to my favorite list Lien TDM:  Générale et digestive > Estomac et duodénum > Hernie hiatale, reflux > Volumineuses hernies hiatales J Leroy (France) September 2004 English - 25'00''   Regarder la vidéo 00'21''  Case presentation This is the case of a para-esophageal hernia in a 60-year-old male patient as is usual in this pathology. This patient is a little obese and weighs 90 Kgs and is 170cm tall. The patient is in a supine position. As can be seen, we have drawn on the abdomen a few landmarks: the subcostal area, the xiphisternum limit, the umbilicus, 4 vertical lines, the midline, the mid-clavicular line on the left, on the right. We will introduce the port at mid-distance between the tip of the xiphoid process and the umbilicus, and a little to the left, it will be the gastric port for the optic. We immediately control that we are in the abdominal cavity and this is the case. We immediately control that the Veress needle has been well introduced. We will introduce the other ports: the subxiphoid port to introduce a retractor, it’s a 5mm port. Then another 5mm port is introduced on the right side of the round ligament. When we introduce the port, we do it in the direction of the hiatus. We then introduce another 5mm port externally. Both subcostal ports will be used to operate. This port will be used to retract the stomach caudally, and this one to retract the liver upward. Now we introduce the Endoflex® retractor through the subxiphoid port. As you see in this type of hernia, it’s usual to have a retraction of the pars condensa of the lesser omentum. We also have a retraction of the stomach, the omentum, and we see the big sac very well. The 1st step is to reduce and maintain the stomach in the abdominal cavity. The fundus is usually retracted and it’s necessary to grasp the stomach with an atraumatic grasper. We see very well the right crus through the lesser omentum and as usual, the hernia sac not only anteriorly but also posteriorly. As you can see, we have the posterior sac and it will be necessary to retract the stomach posteriorly to dissect the sac completely. I always begin to dissect the sac, just close to the hiatus. After opening the peritoneum, the abdominal pressure will progressively help do the pneumodissection and the mobilization of the hernia sac. I usually begin on the left part of the hiatus. If necessary, I will introduce another port on the left side as proposed by Rossetti. The position of the ports will depend on whether we have to dissect. The 1st step is the reduction of the stomach as you see. Now we have completed to evert the hernia sac anteriorly and we will complete the posterior and right dissection of the hiatus. For this, we will introduce a new port, and we use the grasper to reduce the posterior herniation of the cardia and also to expose the right crura. We keep the left hepatic pedicles because it’s a landmark for the valve and to be sure that we are on the lower part of the esophagus, and for the mobilization of the esophagus, we will be sure that we are really around the esophagus because we are above this landmark. I remove it and push it anteriorly. Now I have to find a plane and as usual, we have a big lipoma, and we have to remove it caudally at the end. Here’s the sac and the lipoma. It’s the posterior aspect of the hernia sac that we will completely dissect probably from the left to the right. We will complete the dissection afterwards. It’s the esophagus, and the hernia sac around the esophagus. The hernia sac is not completely separated from the left crus and of the posterior upper part of the low mediastinum. To do this dissection, it’s usually better to use Harmonic scissors. As you see, when we begin this division of the superior short gastric vessels, we will see better and better the left crus, and particularly the external edge of the left crus. We have now completely mobilized the left crus. We complete the division of the attachments of the hernia sac to the left crus as is visible here. Now we mobilize the esophagus in the mediastinum and put a ribbon loop around the esophagus to exert a caudal traction. It is an intramediastinal mobilization of the esophagus and the right crus and we have a big defect. What can be done too is to complete the mobilization of this superior part of the pars flaccida and pars condensa of the lesser omentum, respecting the vessels and the nerve as you now see. Now we must make sure that the stomach and the esophagus stay in the abdomen and dissecting the hernia sac from the esophagus. When we completely close posteriorly and perform the cruroplasty, the length of the esophagus will increase into the abdominal cavity. Why is it better to achieve a posterior cruroplasty? Well, it’s not only my opinion, but it’s because it will increase the length of the esophagus into the abdominal cavity and the esophagus will be on the abdominal pressure. Ninety percent of authors do that otherwise if you don’t, it is recommended you use an anterior patch with the mesh: it will ensure a tension-free suture. You won’t have any increased pressure and it’s an anatomical reconstruction of the hiatus. It’s not too much. You have to make a loop. It’s a tension-free suture. Usually, authors also recommend the use of a gastric tube. I place my grasper and knot pusher here. You don’t have to completely close the loop but you have to lock it. Afterwards if we reinforce this suture, some authors recommend doing a gastropexy to the diaphragm or to the mesh in the abdominal cavity, with or without a gastrostomy, carrying out stomach decompression and then gastrostomy ensures the fixation of the stomach on the abdominal wall. We will introduce this part of the stomach easily around the esophagus. It’s easy to push in this case. You can see that the esophagus and the fundus stay in the abdominal cavity. The 1st stitch is fixed around the right crus. One of the arguments put forward to do an anterior cruroplasty is if you respect the posterior attachments of the esophagus and the cardia, so no posterior dissection, there is a lower risk of esophageal motility disorders. That’s why some authors propose no posterior dissection of the esophagus and posterior attachments, but you have seen that we also have a hernia sac posteriorly, so you don’t probably reduce the cardia completely into the abdominal cavity and I’m not sure it’s well. Because when you have finished dissecting posteriorly, you can complete anteriorly but not totally anteriorly as we do usually but if you have no good crura, it’s probably necessary to complete your sutures with the mesh. There is a high risk of complication with Prolene but it was not really described, it’s only a historical description for inguinal hernia repair and the anesthetist has explained that this patient has a subcutaneous emphysema on the neck.

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