Laparoscopic Hiatal Hernia Repair

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This month’s technique: Laparoscopic Hiatal Hernia Repair

This Month’s Featured Experts: Christopher Armstrong, MD, FRCSC, and  Ninh T. Nguyen, MD, FACS

Both authors are from Department of Surgery, University of California Irvine Medical Center, Orange, California

Bariatric Times. 2012;9(11):8–9

Funding: There was no funding for the preparation of this manuscript.

Disclosures: The authors report no conflicts of interest relevant to the content of this article

Introduction
Paraesophageal hiatal hernia is a common condition associated with gastroeosphageal reflux. Hiatal hernias can be categorized into four types: sliding hiatal hernia (type I), paraesophageal hiatal hernia (type II), a combination of type I and II hiatal hernia (type III), and lastly a hiatal hernia with involvement of other organs, such as the spleen or colon (type IV). Laparoscopic repair of a paraesophageal hiatal hernia was first described by Cuschieri in 1992.[1] Compared to the open approach, the laparoscopic approach shortens hospital stay, reduces perioperative morbidity, and hastens patient recovery.[2] Laparoscopic repair has been shown to have similar efficacy and durability as the open approach.[2,3] The technical difficulty of performing a hiatal hernia repair is dependent on the size of the hernia, the presence of a shortened esophagus, the presence of strangulation/incarceration or volvulus, as well as the presence of other organs within the hernia sac. The goals for the laparoscopic approach include the following: laparoscopic reduction of the herniated contents, mobilization of the gastric fundus, complete dissection of the hernia sac, mobilization of the esophagus to re-establish enough esophageal length, posterior and possibly anterior crural re-approximation, placement of bio-absorbable or biologic mesh, and construction of a Nissen fundoplication.

This article describes how we perform a laparoscopic hiatal hernia repair at our institution—the University of California Irvine Medical Center, Orange, California.

Procedure
Position. The patient is positioned supine with arms extended. The legs should be well padded and secured. Steep reverse trendelenburg positioning is often required and, therefore, at our facility we routinely use a foot block to further ensure the patient will not slide during the operation.

Port placement. We use a standard port placement for most bariatric/foregut procedures performed at our institution (Figure 1). This consists of establishment of pneumoperitoneum using a veress needle placed in the left abdomen lateral to the umbilicus at the edge of the rectus abdominis. A 12mm trocar is then placed at this site. We then place a 5mm port in the subcostal region beneath the inferior edge of the liver at the mid-axillary line to use for a fixed liver retractor. A 5mm port is placed in the subcostal region at mid-clavicular line and a 12mm port just slightly cephalad and to the right of the umbilicus serve as the surgeon’s main operating port. A final 5mm trocar is placed in the left upper quadrant and utilized by the assistant.

Operative Steps
1.    Expose the diaphragmatic hiatus by retracting the left lateral segment of the liver (Figure 2).
2.    Reduce stomach and hiatal hernia sac by mobilizing the gastric fundus. Dissection begins with takedown of short gastric vessels (Figure 3) and proceeds toward the diaphragmatic hiatus (Figure 4) to fully expose the left diaphragmatic crus.
3.    Complete circumferential dissection of the hiatal hernia sac at the level of diaphragmatic hiatus. It is often easiest to gain entry into the proper plane immediately adjacent to the left crus (Figure 5). The correct plane is bloodless and involves division of loose areolar attachments. The right crus is approached by dividing the pars flaccida and dissected until the left crus is visualized. It is important preserve the integrity of the crura during this phase of the dissection.
4.    The mediastinal dissection continues in a cranial direction to obtain enough intra-abdominal esophageal length (minimum 2cm [Figures 6 and 7]).
5.    Re-approximation of the diaphragmatic crura is performed posterior to the esophagus using the endostitch suturing device with 2-0 non-absorbable suture. A laparoscopic crimping device is used to secure the suture (Figure 8).
6.    The crural repair is then buttressed using a pre-cut bio-absorbable mesh. The mesh is attached to the left and right crura (Figure 9).
7.    A Nissen fundoplication is then constructed. We routinely use three interrupted sutures, each incorporating a small bite of the underlying esophagus to construct a 2cm length wrap (Figure 10). It is important to ensure a loose wrap around the esophagus in order to minimize the risk of postoperative dysphagia. We do not routinely use a bougie to calibrate the fundoplication.
8.    The completed wrap is then anchored to the hiatus using interrupted 2-0 nonabsorbable sutures. Typically, four sutures are required to anchor the wrap to both the right and left crura as well as the anterior aspect of the diaphragmatic hiatus (Figures 11 and 12).
9.    We perform an intraoperative endoscopy to assess position of the wrap, rule out perforation, and ensure the wrap has not been constructed too tightly (Figure 13).

Postoperative Care
Patients are kept nil per os (i.e., without oral food or liquid) over night with patient-controlled analgesia. Anti-emetics should be given liberally to help reduce vomiting or retching in the early postoperative period. An upper gastrointestinal (UGI) contrast study is performed on Postoperative Day 1 to assess the position of the wrap and rule out any inadvertent perforation (Figure 13). Patients are then transitioned to clear fluids and are typically discharged from hospital on the first postoperative day.

References
1.    Cuschieri A, Shimi S, Nathanson LK. Laparoscopic reduction, crural repair, and fundoplication of large hiatal hernia. Am J Surg. 1992;163(4):425–430.
2.    Nguyen NT, Christie C, Masoomi H, et al. Utilization and outcomes of laparoscopic versus open paraesophageal hernia repair. Am Surg. 2011;77(10):1353–1357.
3.    Schieman C, Grondin SC. Paraesophageal hernia: Clinical presentation, evaluation, and management controversies. Thorac Surg Clin. 2009;19(4):473–484.

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery