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Dallemagne B, Marescaux J. Large type III hiatal hernia repair with a biological diaphragmatic mesh and partial posterior fundoplication. Epublication: WeBSurg.com, Jun 2008;8(6). URL: http://www.websurg.com/ref/doi-vd01en2350.htm
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English - 18'55''
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June 2008
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This video presents the management of a giant hiatal hernia by a laparoscopic Toupet fundoplication. We use a combination of pledgets and sutures as well as a mesh to close the crural defect. We recommend this video for advanced upper GI surgeons.
| 00'09'' | Introduction
The treatment of the large type 2 or 3 hiatal hernia is still controversial. In the majority of the cases, the surgeons agree that the different steps of reduction of the hernia, reduction of the sac of the hernia, excision of the sac is quite common. Everyone today agrees that the approach to the large hiatal hernia has to be outside of the hernia sac. We know by experience that getting directly into the sac may lead to big problems when looking for the different landmarks, when we try to identify the esophagus, the vagus trunk etc. |
| 01'03'' | Approach - out of the sac
We consider today that the approach to the sac has to be outside in the mediastinum and we can see that this approach allows to identify the main structures like the left pleura and it allows to find the exact dissection plane between those mediastinal structures. In comparison, if we go straight into the sac, we can\'t identify these structures. The consensus is this extrasacular approach. |
| 01'50'' | Pleura dissection
On this picture, we can see that the pleura is progressively retracted and separated from the hernia sac, then the dissection follows the relief of the hiatal orifice and progressively with blunt dissection, we can retract, excise and dissect the sac from this mediastinal structure. |
| 02'30'' | Esophageal and sac dissection
This access allows a direct view of the esophagus, which is one of the major structures of the mediastinum, and by continuing this dissection along the orifice, we can gradually get access to the superior part of the sac and directly to the supra-sacular structure and of course the esophagus. One important point when dissecting this big sac is to work quite deeply and extensively on the left crus because we know that there are very strong attachments on the lower part of the left crus and usually when we divide these strong attachments, the reduction of the sac is far more easier. We mostly use blunt dissection, we don’t think that using special devices such as the Ligasure or a hook are very helpful in this part of the dissection because to reproduce the blunt dissection with these instruments is quite difficult. Good traction on the hernia sac is really important in order to expose the hiatal structures, progressively the sac is reduced into the peritoneal cavity. Identification of the structures such as the vagus trunk is also very important. |
| 04'18'' | Mediastinal dissection
The mediastinal dissection is very extensive, it is the tedious part of the operation but it is an essential part of the operation because one of the goals is to get the GE junction back into the peritoneal cavity. Posterior dissection of the esophagus is crucial, it is a very important step of the operation and therefore we need very clear landmarks, this landmark is the left crus. Some people start the dissection from the left side, this means they start on the left crus and progressively move to the right crus. We are used to going from right to left but both procedures are very good. |
| 05'09'' | Intramediastinal esophagus dissection
In order to avoid instrumental traction on the digestive structures, we use an umbilical tape, which is passed around the GE junction, it allows to get a very good traction on the junction and to expose the intra-mediastinal esophagus. As soon as we get this traction, the intra-mediastinal dissection is made easier. During all these steps, we have to have a clear view of the position of the vagus trunk, again by blunt dissection and some cutting with the ultrasonic scissors; we can progressively mobilise the upper part of the esophagus and sometimes dissection up to the pulmonary vein or even to the infracarinal lymph nodes is necessary to get a good length of the esophagus back without traction below the diaphragm. An important step of the operation is to work on the left side of the esophagus, usually we can find quite strong adhesions between the left border of the esophagus and mediastinal structures, but at this stage of the mobilisation, we have to take care of the anterior vagus trunk, which takes an oblique direction to the left of the patient. The perception and identification of this vagus trunk is very important. |
| 06'54'' | Esophageal length assessment
As soon as we have mobilised the esophagus, we can access the length of the esophagus, which is brought back into the peritoneal cavity. Sometimes in patients with a short esophagus, the question is on the use and necessity of the lengthening procedure. |
| 07'17'' | Hernia sac excision
All the surgeons also agree on the importance of the division and excision of the hernia sac, we feel that it is quite important because it will probably stabilise a little the junction below the diaphragm. Second reason is that if we are adding some sort of anti-reflux repair, it is better to have a quite clean GE junction in order to properly place the fundoplication. We perform routinely the excision of the hernia sac. The umbilical tape that we have placed on the GE junction shows there is no retraction of the GE junction into the mediastinum, that is an important parameter when dealing with this sort of surgery. |
| 08'11'' | Fundus mobilisation
We routinely mobilise the upper part of the gastric fundus, there are different advantages. One is that if we are creating an anti-reflux repair such as a Nissen fundoplication, we prefer to do it floppy and that is why we are always mobilising even in these large hiatal hernias where we can think that the short gastrics are not short anymore, it gives a good mobility of the upper part of the gastric fundus, which is very helpful in creating the anti-reflux mechanism. |
| 08'49'' | Crura closure
One of the most controversial points is the technique to close the crura, in a lot of papers published in the literature talk of the need for reinforced crura repair. Different techniques have already been demonstrated in WeBsurg, some use pledget sutures, in this technique we use a combination of pledget sutures done with a bio-absorbable material, Surgisis, and we create two small pledgets, that reinforce the suture that are placed on both crura so we could end up with this sort of repair but in this case because the diaphragm is quite fragile, we decided to add some mesh reinforcement. So a mixture of pledget suture and a biological mesh which is placed on the crura repair and on the diaphragm. Here we are using a non-absorbable suture, Ethibond 0 and the suture is reinforced with the pledgets. Intra-corporeal and extra-corporeal suturing can be used when dealing with this difficult step of the operation. Calibration of the repair may be important in some patients, but usually we try to repair the crura in order to size the diameter of the esophagus. Sometimes the use of a 50 or 60 French bougie may be very helpful. A combination of posterior stitches and anterior or anterior-lateral stitches is necessary to close this very large hiatus and we can see on the anterior part of the diaphragm that the structures are very fragile, that also explains why in this precise patient we decided to use some reinforcement. This biological mesh is in fact acellular matrix which will be colonised by the cells of the patient. It is not an absorbable material but it is probably less aggressive material than the usual polypropylene or PTFE mesh. This mesh is fixed on the posterior crura repair, that will stabilise the mesh, sometimes it is difficult to place the mesh because the structure is not very easy to handle but using these stabilising sutures, they become progressively very helpful in getting a good position of the mesh. A tailored mesh is used, so we are sizing the mesh on the size of the hiatus and the position of the esophagus, in fact we are trying to avoid as much as possible contact between the mesh and the esophagus. We do not care about contact between the mesh and the gastric wall. Why sutures and not tackers? Complications have been reported in the literature on the use of tackers in this area, with some cardiac tamponade and death of the patient. This repair is very well sized on the esophagus, we try to avoid a too large distance between the esophagus and the crura, you can see that again we are trying to avoid direct contact between the mesh and the esophagus. This is a final view of the crura repair, there is no stenosis of the esophagus and this acellular matrix will reinforce the diaphragm. |
| 13'29'' | Anti-reflux procedure
We will finish this operation by adding some anti-reflux repair, in a majority of patients we use a total floppy Nissen fundoplication, in some patients with thoracic or pulmonary symptomatology, we prefer to do a partial posterior fundoplication Toupet-like technique, which may have less side-effects than a total fundoplication in this precise category of patients. To that, as usual we place sutures on both the left and right side of the esophagus to create this posterior anti-reflux mechanism. When doing this posterior repair, we are used to stabilising a little bit the repair on the posterior cruroplasty, that may help in preventing some postoperative herniation. The use of this anti-reflux mechanism is recommended by the majority of the authors because the extensive dissection provokes some reflux after the operation. |
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