Laparoscopic Paraesophageal Hernia Repair

Contributors: Reza Salabat and Marco P. Fisichella

Preoperative work-up and surgical technique of laparoscopic paraesophageal hernia repair.

DOI#: http://dx.doi.org/10.17797/c2kvm64ru5

LAPAROSCOPIC PARAESOPHAGEAL HERNIA REPAIR A 74-year-old man seeks medical attention for intermittent epigastric pain and daily regurgitation. During each meal he experienced early satiety and nausea. He also experienced dyspnea that worsened during exertion. His past medical history is relevant for rheumatoid arthritis and mitral valve regurgitation. A Barium swallow evaluation of the upper GI was performed, demonstrating an organ-axial volvulus with the entire stomach in the chest. Esophageal manometry was normal.
Severe symptoms, gastric volvulus.
There are no contraindications to a laparoscopic approach as the patient is otherwise healthy.
The patient lies supine on the operating table in low lithotomy position with the lower extremities extended on stirrups with knees flexed 20-30, a bean bag is inflated to avoid sliding of the patient; an oro-gastric tube is placed to decompress the stomach; the surgeon stands between the patient's legs, while first and second assistant stand on the right and left side respectively. A four trocar technique is used for this procedure; a first trocar is placed 14 cm inferior to the xiphoid process, in the midline, for a 30����¯�¿�½������° laparoscope; two trocars are placed below each costal margins at the level of the midclavicular line and they are used for the dissecting and suturing instruments; another trocar is placed at the left anterior axillary line, at the same level with the first trocar; a liver retractor is placed through a stab incision to the left of the xyphoid process and secured to the patient's bed.
Essential investigations are barium swallow and esophageal manometry.
Excluding placement and removal of trocars, we can consider seven major steps for this surgery. 1. Reduction of the hernia. 2. Section of the phrenoesophageal membrane 3. Hernia sac dissection and resection. 4. Section of the short gastric vessels. 5. Dissection of the posterior mediastinum and esophageal mobilization. 6. Crural repair. 7. Fundoplication.
The patient starts a soft diet the morning of the first post-operative day; it's important to avoid meat, bread and carbonate beverages for 2 weeks; the patient was discharged within 23h after the operation. A barium swallow is usually obtained between 6 and 12 months post-operatively to assess for any recurrence.
No complications occurred.
- Fisichella PM, Allaix ME, Morino M, Patti MG - Esophageal Diseases. Evaluation and Treatment. Springer Edition. - Fisichella PM. A synopsis of techniques for paraesophageal hernia repair: different approaches to current controversies. Surg Laparosc Endosc Percut Tech. 2013;23(5):423-4. - Dallemagne B, Kohnen L, Perretta S, et al. Laparoscopic repair of paraesophageal hernia. Long-term follow-up reveals good clinical outcome despite high radiological recurrence rate. Ann Surg. 2011;253:291-6. - Weber C, Davis CS, Shankaran V, Fisichella PM. Hiatal hernias: a review of the pathophysiologic theories and implication for research. Surg Endosc. 2011;25(10):3149-53. - Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of paraesophageal hiatal hernias. J Am Coll Surg. 1998;186:428-32.

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