Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.
This is a video showing laparoscopic mesh repair of a large, defined as greater than seven centimeters in length, sliding hiatus hernia using Gore Bio-A Mesh. This patient is a 68-year-old who presented with reflux symptoms, unresponsive to medical treatment and iron-deficiency anemia. Subsequent gastroscopy found Cameron lesions, large linear erosions in the gastric body and a 10 centimeter rolling hiatus hernia, compared to four centimeters in the previous gastroscopy a year ago.
Prior to surgery, the patient was given Optifast for one week to reduce the liver size and assist the liver retraction intraoperatively. Establish pneumoperitoneum of 12 millimeters of mercury via a left subcostal Veress needle at Palmer's point. defined as three centimeters below the subcostal margin in the left midclavicular line.
Using a direct bladeless optical access entry system, insert the port, which is supraumbilical, one hand span from the costal margin and to the left of the midline for the camera. Elevate the left lobe of the liver with a Nathanson liver retractor through a small left paraxiphoid incision. Place two further five millimeter ports under direct vision alongside the camera port.
One at the level of the right midclavicular line. The second port on the left anterior auxiliary line. Insert a 10 millimeter port that is more cephalad at the left midclavicular line to create an ideal working triangulation.
At this stage, most of the stomach will be herniating into the mediastinum. Therefore, pull the incarcerated stomach back into their abdominal cavity with continuous traction from the assistant to view the gastroesophageal junction. Enter the lesser curvature at the level of the pars flaccida of the gastrohepatic ligament and progressively dissect, reduce and excise the hernia sac using cauterization.
This will lead to gradual exposure of both diaphragmatic crura. Note is made of the inferior vena cava and the caudate lobe of the liver in relation to the right crus. Mobilize the esophagus circumferentially by dividing all the congenital paraesophageal adhesions within the hiatus.
Continue mobilizing the hiatus hernia off the bilateral crura to assist in retracting the hernia sac into the abdominal cavity. Identify and preserve the vagus nerves and both pleura. Create a window posteriorly between esophagus and thoracic aorta and place tape around the distal esophagus to allow gentle retraction.
Mobilize the distal esophagus proximally, about 10 centimeters in distance, until there is adequate intraabdominal esophageal length, which is about three to four centimeters and so the esophagus lies free of tension. Approximate the diaphragmatic crura with three or four interrupted 1-O nonabsorbable braided sutures and reinforce the repair with a pre-shaped biosynthetic mesh that is introduced behind the esophagus in an onlay fashion. The right edge of the mesh should slide under the caudate lobe of the liver.
If necessary, divide the left triangular ligament to accommodate the mesh. No pledgets are required if the quality and the tension of the crura is adequate. The extent of the crura closure should not cause narrowing or compression on the lower esophagus.
A rough guide to adequate closure is being able to pass a grasper through the remaining gap. Secure the biosynthetic mesh with four mLs of fibrin glue. Perform a modified 180 degree anterior Dor fundoplication using 2-O nonabsorbable braided sutures by suturing the gastric fundus to the left crus, then sequentially fixing the folded greater curvature of the stomach anteriorly to the diaphragm and all the way to the proximal right crus.
Four sutures are usually required. Incorporate the mesh into the first suture. Take care not to injure the pericardium during the fundoplication.
A Bougie is not used. Insert a closed suction drain. Close skin with subcuticular 3-O synthetic absorbable and monofilament sutures.
Postoperatively, the patient is nursed with the head elevated to 30 degrees to avoid aspiration. The patient was placed on regular antiemetics. The patient is allowed sips of water overnight followed by clear fluids if tolerated.
The drain is usually removed after two days. The patient is advised to have a puree diet for four to six weeks.Results. 32 patients have undergone this technique.
Of this, 26 were female and six were male. The median follow-up was 19 months. The median age for this group was 72 years of age.
Of these 32 patients, four were type one, all of these were greater than seven centimeters, 23 would type three, of which three were recurrent, and lastly, four were type four. Of these patients, there was one recurrence and one mortality. This patient had a recurrent type three hiatus hernia, and this was a difficult dissection.
Postoperatively, this patient was quite well and tolerated fluids well for the first 48 hours. She then unexpectedly rapidly decompensated from unrecognized cardiac tamponade.Conclusion. The key points for this procedure includes one, complete and circumferential mobilization of the hiatus hernia with excision of the sac.
Two, adequate exposure and crura repair. Three, reinforcement of the cruroplasty with biosynthetic mesh. Four, further reinforcement of the repair with a modified 180 degree anterior Dor fundoplication.
Using this technique, a low recurrence rate can be achieved. However, the patient should have ongoing followup with regular endoscopy. A healthier lifestyle is also encouraged.
