Paraesophageal hernia

Question 1

Which of the following statements is not true regarding paraesophageal hernias

A. Most cases of hiatal hernias are acquired
B. All paraesophageal hernias should be repaired upon diagnosis.
C. Patients tend to eat very small meals to avoid feeling uncomfortable.
D. Anemia is commonly present in these patients

Answer 1

Ans B -

It was though that all PEH should be repaired upon diagnosis. Recent evidence however has suggested that a non-surgical approach is reasonably safe in asymptomatic patients. Surgical intervention is recommended for patients with symptoms or signs associated with a PEH.

Symptoms can be subtle and include chest pain after meals, dysphagia for solids, dyspnea on exertion out of proportion to general health, early satiety and the need to eat very small meals to avoid feeling discomfort.

Anemia is a common condition in these patients and typically resolves with the correction of the hernia.

Most cases of hiatal hernia are acquired rather than congenital although familial clustering has been reported.

Shackleford 8e Pg 279.

Pooled annual probability of developing symptoms was estimated to range between 0.69% and 1.93%. The lifetimes risk of developing acute symptoms decreases exponentially as the patient’s age increases.
Watchful waiting would be more beneficial than elective repair in more than 80% patients of PEH.

Patients who have symptoms of acute incarceration or strangulation should undergo prompt surgical repair. Patients with obstructive symptoms, bleeding, or respiratory symptoms attributed to their paraesophageal hernia should also undergo surgical repair.

Most patients develop symptoms of GERD after PEH repair, and unless there is a contraindication these patients would benefit from fundoplication procedure in addition to their hiatal hernia repair.

Shackleford 8e Pg 282, 283

Most surgeons feel that very old or debilitated patients should not undergo surgery whereas younger patients with life expectancy of 5-10 years should consider surgery, especially if more than 50% of stomach lies in the chest and potentially progressive symptoms.

Mortality rate from elective repair is estimated to be 1.4% and probability of developing acute symptoms that would require emergency surgery was 1.1%.
Patients with an intrathoracic upside down stomach who have obstructive symptoms at initial presentation should undergo repair and that elective operation is safe and effective.

The lifetime risk of developing acute symptoms requiring emergency surgery decreases exponentially with age older than 65 years.

Shackleford 8e Pg 291.

Question 2

Which of the following statements is true regarding Type I hiatal hernia -

A. GE junction always remains above the stomach
B. decreased amount of collagen I and III in phreno-esophageal ligament.
C. migration of GE junction into posterior mediastinum
D. All of the above

Answer 2

Ans D -

Type I hiatal hernia is a migration of the GEJ into the posterior mediastinum which is usually a result of deterioration of the phreno-esophageal ligament.
Different types of collagen, typically type I and III are reduced in the phrenoesophageal ligament of these patients.
The GE junction remains above the herniated stomach in this variant.

Shackleford 8e Pg 279.

Question 3

Hernia sac is not found in which of the following PEH

A. Type I
B. Type II
C. Type III
D. Type IV

Answer 3

Ans A -

Type II, III and IV are para-esophageal hernias where the stomach and esophagus are juxtaposed. A paraesophageal hernia is a true hernia with a hernia sac.
The key feature is that the fundus is of the stomach is located above the level of GE junction.

Shackleford 8e Pg 279.

Question 4

Which of the following is a true paraesophageal hernia

A. Type I
B. Type II
C. Type III
D. Type IV

Answer 4

Ans B -

The location of the fundus relative to the GE junction defines a sliding versus a paraesophageal hernia. Type II or “Rolling” hiatal hernias, occur when the gastric fundus herniates anterior to the esophagus, with a normally positioned intra-abdominal GE junction. Type II is also referred to as a “true” paraesophageal hernia.

Shackleford 8e Pg 279.

Question 5

giant paraesophageal hernia is defined as -

A. Presence of small bowel and other organs in the mediastinum besides stomach
B. more than 50% of the stomach herniated
C. Hernia measures more than 6cm on endoscopy
D. both B and C

Answer 5

Ans D -

Presence of small bowel, colon, pancreas or spleen etc along with stomach is type IV PEH.

The term giant paraesophageal hernia refers to large hiatal hernias where atleast 50% of the stomach is in the mediastinum or the hernia measures atleast 6cm on endoscopy

Shackleford 8e Pg 279.

Question 6

which if the most common hiatal hernia

A. Type I
B. Type II
C. Type III
D. Type IV

Answer 6

Ans A -

the most common hiatal hernia is type I - it accounts for 95% of the hiatal hernias.

shackleford 8e Pg 279.

Question 7

Which of the following is the most common paraesophageal hernia

A. Type I hiatal hernia
B. Type II hiatal hernia
C. Type III hiatal hernia
D. Type IV hiatal hernia

Answer 7

Ans C -

Paraesophageal hernias may account for upto 14% of all hiatal hernias and the majority of paraesophageal hernias are of the type III variety. The incidence of paraesophageal hernias increases with age.

Shackleford 8e Pg 280

Question 8

Paraesophageal hernia most commonly occur on

A. Left posterior
B. Left anterior
C. Right posterior
D. RIght anterior

Answer 8

Ans B -

Paraesophageal hernias develop on the left anterior aspect of the esophageal hiatus.

Women are more likely to develop paraesophageal hernias compared to men

Kyphosis is a risk factor for the development of hiatal hernia.

Shackleford 8e Pg 280.

Question 9

Most common symptom of paraesophageal hernias is -

A. Typical heartburn
B. dysphagia
C. Epigastric pain
D. Vomiting

Answer 9

Ans A

Typical heartburn is present in 47% of the patients, compared to dysphagia in 35%, epigastric pain in 26% and vomiting in 23%.

Shackleford 8e Pg 280.

Question 10

Cameron ulcers are seen in -

A. GERD
B. Achalasia
C. Hiatal hernia
D. gastroparesis

Answer 10

Ans C -
Cameron ulcers are linear erosions seen in patients with large hiatal hernias.

Many patients have endoscopic evidence of gastritis and Cameron Ulcers. It has been postulated these gastric ulcers can result from gastric torsion and poor gastric emptying.

Shackleford 8e Pg 280.

Question 11

Organoaxial gastric volvulus is defined as -

A. Turning of the stomach around is long axis
B. Turning of the stomach around is short axis
C. Turning of the stomach around its antero-posterior axis
D. None of the above

Answer 11

Ans A -

A gastric volvulus can occur when the stomach turns around its long axis called organoaxial, or when it turns on its short axis, called mesentroaxial.

Organoaxial is the most common type of gastric volvulus occuring in more than 2/3 of the cases.

Shackleford 8e Pg 280.

Question 12

Which of the following is not a part of the Borchardt’s triad

A. Inability of vomit
B. Severe retching
C. inability to pass a ryle’s tube
D. periumbilical pain

Answer 12

Ans D -

Borchardt’s triad is the classical triad of gastric volvulus. It includes

• Chest pain or epigastric pain
• Retching and inability to vomit
• inability to pass the ryle’s tube into the stomach.

Shackleford 8e Pg 280.

Question 13

which of the following is not true regarding Cameron ulcers

A. They are more common along greater curvature
B. at the level of the diaphragmatic hiatus
C. more likely to be present in patients with anemia and hiatal hernia
D. can be multiple

Answer 13

Ans A

Bleeding can be caused by ischemia or ulcers within the herniated stomach. Cameron lesions are single or multiple gastric erosions or ulcerations that can be seen at the diaphragmatic hiatus. The most common location is on the lesser curve of the stomach at the level of diaphragmatic hiatus.
Patients with paraesophageal hernia with anemia were 7x more likely to have evidence of linear ulcerations or erosions in the gastric mucosa compared with patients who had paraesophageal hernias without the evidence of bleeding.

Shackleford 8e pg 281.

Question 14

Most accurate information regarding the anatomy and location of paraesophageal hernias -

A. Endoscopy
B. Barium esophagogram
C. Manometry
D. Chest X ray

Answer 14

Ans B -

Barium esophagogram can be useful in the diagnosis of PEH and often gives the most accurate information regarding the hernia’a anatomy and location. An esophagogram can help differentiate between type II and Type III hiatal hernias.
A right anterior oblique technique is useful.

Shackleford 8e Pg 281.

Question 15

which of the following is true regarding para-esophageal hernia?

A. The lifetime risk of developing acute symptoms decreases exponentially as the patient’s age decreases.

B. Operative intervention is recommended in asymptomatic cases

C. Mortality was highest in patients older than 75 years of age for repair.

D. Fundoplication is usually not recommended as part of the repair

Answer 15

Ans C -

The life times risk of developing acute symptoms decreases exponentially as the patient’s age INCREASES.

Watchful waiting would be more beneficial that elective PEH Repair in over 80% patients.

Patients who have symptoms of acute incarceration or strangulation should undergo prompt surgical repair. Patients with obstructive symptoms, bleeding, or respiratory symptoms attributed to their paraesophageal hernia should also undergo surgical repair.

Mortality was highest in patients over 75 years of age for hernia repair.

Unless there is a contraindication, these patients would benefit from a fundoplication procedure in addition to hernia repair.

Shackleford 8e Pg 283.

Question 16

which of the following is not an indication for repair of PEH

A. Large PEH
B. Minimally symptomatic
C. Asymptomatic
D. Significant weight loss

Answer 16

Ans C

Less than 5% of patients of PEH are truly asymptomatic when questioned thoroughly. Repair is generally recommended for all symptomatic patients.

Patients billed as asymptomatic frequently suffer from significant symptoms such as shortness of breath, that may not be attributed to the hernia.

Life threatening events are lower than the risk of undergoing repair.
When these hernias progress to requiring semiurgent, non-elective repair they are associated with significantly increased risk.

Risk of perioperative mortality and/or morbidity can be estimated to some degree by the

• size of the PEH
• Functional status
• comorbid conditions
• symptom complex

Large hernias are more likely to have obstructive symptoms and to present urgently when compared with patients with smaller (<75% gastric herniation) PEH.

Recommend elective surgical repair for most patients who have minimal symptoms and very large PEH.

Shackleford 8e Pg 285, 286.

Question 17

which of the following is not a contraindication for elective repair of PEH

A. Portal hypertension
B. Age
C. Significant hematologic clotting disorder
D. Inability to tolerate GA

Answer 17

Ans B -

Relative contraindications to laparoscopic PEH repair include portal HTN, significant hematologic clotting disorders, and contraindications to surgery in general such as inadequate cardiovascular function or the inability to tolerate general anesthesia.
Age itself should not be considered a contraindication since most of these patients are elderly and will be even less likely to tolerate urgent or emergent surgery but typically do very well with elective laparoscopic repair.

Shackleford 8e Pg 286.

Question 18

which of the following is the gold standard investigation for the evaluation of PEH

A. Barium Esophagogram
B. Manometry
C. Endoscopy
D. CECT chest

Answer 18

ANS A -

We consider barium esophagogram as the gold standard for evaluation of PEH because it is inexpensive, low risk and provides an accurate assessment of the degree of gastric herniation and the anatomic relationship between the stomach, GEJ, and diaphragmatic hiatus.

Shackleford 8e pg 286.

Question 19

which of the following is not a key element of the PEH repair?

A. Gastropexy
B. Preservation of the peritoneal lining of the crural bodies
C. Mediastinal mobilisation and Collis Gastroplasty
D. None of the above

Answer 19

Ans D -

To optimize repair durability and to ensure long term symptom resolution, PEH repair requires strict attention to several key elements -

A. Complete reduction of the hernia sac and contents
B. Careful preservation of the anterior and posterior vagus.
C. Mobilisation of GE fat pad, resection of excess hernia sac, and identification of the GEJ.
D. recognition and management of shortened esophagus
E. Extensive mediastinal mobilisation and performance of Collis Gastroplasty when necessary
F. Preservation of crural integrity with absolute requirement that the peritoneal lining of the crural muscle bodies remain intact.
G. Closure of the hiatal defect without tension
H. Consideration of mesh reinforcement of the primary crural closure
I. Addition of a full or partial fundoplication, or in select cases addition of a gastropexy.

Shackleford 8e Pg 286.

Question 20

During PEH repair, tension on the crura can be reduced by all of the following except -

A. Complete esophageal mobilisation and preservation of crural integrity

B. Freeing up the spleen from the edge of the left crus.

C. Controlled tension pneumothorax to the left side.

D. Creating an “speed bump” deformity of the esophagus as it passes through the hiatus

Answer 20

Ans D -

A key element to durable repair of PEH is a tension free closure of the hiatal defect.

In vast majority of patients we can achieve primary crural repair if the principles of complete esophageal and sac mobilisation and preservation of crural integrity are followed.

The crura are approximated with 2 or 3 interrupted non-absorbable sutures placed posteriorly with the esophagus lying in a neutral tension free position within the hiatus.

Freeing up the spleen from the edge of the left crus can relieve some of the tension in this location. Normally the spleen lies in the left upper quadrant and is not adherent to the left crus. However after years of gastric migration into the chest, the short gastrics and residual posterior hernia sac can drag the spleen towards the crus and actually cause scarring of the left crural edge.

If tension remains, consider adding a controlled tension pneumothorax (as previously described) to the left side. This creates a very favorable “floppy diaphragm” and in almost all cases, allows a tension free approximation of the crus both anteriorly and posteriorly.

Avoid an artificial angulation or speed bump deformity of the esophagus as it passes through the hiatus from excessive posterior crural closure.

Shackleford 8e Pg 288.

Question 21

All of the following are lifestyle modifications advised after PEH repair except -

A. 25 chew rule
B. 4-5 small meals per day
C. avoid lifting heavy weights
D. carbonated drinks

Answer 21

Ans D -

Routine postoperative care includes -

• barium esophagogram on POD1
• Liquid narcotic pain medication on day 1-3
• avoidance of constpitation
• refrain from heavy lifting long term and limit lifting to 15-20 pounds.
• avoid gassy foods and slowing down the eating process
• avoid excess gas swallowing
• 25 chew rule - chewing each bite of food 25 times.
• 4-5 small meals per day and avoiding large feast type meals.

Shackleford 8e Pg 290.

Question 22

most common major early postoperative complication after PEH repair -

A. Pulmonary Embolism
B. Pneumonia
C. Congestive heart failure
D. Post operative leak

Answer 22

Ans B -

In the early post operative period, major postoperative complications include pneumonia, congestive heart failure and pulmonary embolism.

Post operative mortality in the setting of elective repair should be less than 1% but is higher in patients older than 80 years and in patients requiring urgent repair.

Major adverse outcomes including pneumonia (4%), pulmonary embolism (3.4%), congestive heart failure (2.6%), postoperative leak 2.5%.

Shackleford 8e Pg 290.

Question 23

which of the following is not a risk factor for the development of PEH?

A. Obesity
B. pregnancy
C. Chronic constipation
D. Age
E. COPD and chronic coughing
F. none of the above

Answer 23

Ans F

Obesity, pregnancy, chronic constipation and COPD, strenuous jobs with significant amount of lifting are associated with increased intra-abdominal pressure. Age is also a significant risk factor for the development of PEH.

Shackleford 8e Pg 291.

Question 24

which of the following is an indication for emergency repair of PEH

A. Respiratory compromise
B. Cameron Erosions
C. Aspiration
D. Shortness of breath

Answer 24

Ans A -

Emergency repair is required in patients with acute gastric volvulus, uncontrolled GI bleed, obstruction, strangulation, perforation or irreversible respiratory compromise.

Elective repair is recommended in patients with PEH who experience chronic symptoms that are increasing in frequency and severity such as GERD refractory to medical therapy, dysphagia, early satiety, postprandial chest or abdominal pain, postprandial shortness of breath, aspiration, chronic anemia (Cameron ulcers) or vomiting.

Shackleford 8e Pg 291.

Question 25

which of the following is not performed routinely during pre-operative workup for PEH repair

A. UGI series
B. Endoscopy
C. Manometry
D. CT scan of chest and upper abdomen

Answer 25

Ans C

all patients undergo upper endoscopy, barium swallow/upper GI series, and computed tomography of chest and upper abdomen.
Oral contrast studies provide important information of gastric anatomy but most importantly length of the esophagus. Esophageal manometry and pH analysis are not required because they are unreliable and difficult to perform in this scenario.

Shackleford 8e Pg 292. v

Question 26

The preferred approach for PEH repair in emergency?

A. Laparoscopic trans-abdominal
B. Laprotomy trans-abdominal
C. Transthoracic
D. VATS

Answer 26

Ans A -

Laparoscopic PHER is preffered for most patients both elective and emergency.

However the three approaches have not been compared with one another in randomized trials and the optimal operative approach remains controversial and varies most depending on the surgeon training and experience.

Shackleford 8e Pg 292.

In an analysis approximately 40,000 patients from 1999 through 2008 from the NIS database 74% were performed open transabdominal, 17% were performed transthoracically and 9% were performed laparoscopically.

Currently laparoscopic PEHR has surpassed open transabdominal repair as the most commonly performed procedure for PEHs.

Shackleford 8e Pg 293.

Question 27

Which of the following is not an indication for transthoracic approach for PEHR

A. History of intra-abdominal abscess, infection and contamination
B. BMI>35
C. History of abdominal wall mesh
D. failed previous transabdominal procedures

Answer 27

Ans B -

Open transadbominal approach is used in patients who have had a limited number of upper abdominal procedures in the past, and reserve the transthoracic approach for patients who have

• failed previous trans-abdominal procedures
• history of abdominal wall mesh
• history of abdominal abscess, infection and contamination
• significant elevated BMI >40.

Shackleford 8e Pg 293.

Proponents now advocate a transthoracic PEH repair should be performed instead of a transabdominal repair in patients who are obese, have a true shortened esophagus, have associated esophageal motility disorders, have a complex type IV PEH, have failed at least 2 trans-abdominal repairs, or have a midline abdominal incisional hernia repair with mesh.

Shackleford 8e Pg 296.

Question 28

which of the following approaches is associated with longest postoperative stay following PEHR

A. Transthoracic
B. Transabdominal - open
C. Transabdominal - laparoscopic
D. VATS

Answer 28

Ans A -

In the NIS study, transthoracic approach was associated with the

• greatest hospital stay
• greatest need for mechanical ventilation
• greatest risk for pulmonary embolism

Laparoscopic approach was associated with the shortest postoperative stay and the lowest risk of requiring mechanical ventilation. This is also associated with decreased overall cost.

Although the risk of radiographic recurrence is higher with laparoscopic approach, reoperation rates are similar for both laparoscopic and open surgeries.

Shackleford 8e Pg 293.

Question 29

which of the following is contraindicated for reinforcement or primary repair of hiatal defect of PEHR

A. PTFE
B. Prolone
C. Bovine pericardium
D. Both A and B

Answer 29

Ans D -

Synthetic permanent material such as PTFE and Prolene is contraindicated for reinforcement or primary repair of hiatal defect because of serious and even life-threatening complications including esophageal erosion with ulceration and perforation as well as abscess formation.

If crural fibers are disrupted during the dissection or the primary repair is under tension, the crural closure can be reinforced with biologic mesh such as porcine dermal matrix or bovine percardium.

Biologic and bioresorbable mesh complications are usually only dysphagia as compared with erosion, perforation, stenosis, fibrosis and the need for complex reoperations because of synthetic non-absorbable materials.

Mesh reinforcement of the hiatal hernia closure reduced the recurrence and reoperation rate but the overall complication rate was the same.

Mesh reinforcement is preferrable in -

• women older than 80 years old
• steroid dependent patients
• reoperations
• COPD patients.

Shackleford 8e Pg 293, 294.

Question 30

which of the following is not an advantage associated with transthoracic approach for repair of PEH

A. Accurate assessment of esophageal length
B. Greater ease of performing Esophageal lengthening procedure
C. Decreased postoperative pain
D. greater ease of closure of hiatus without tension
E. Better exposure in obese patients

Answer 30

Ans C -

Thoracic surgeons argue that an open transthoracic PEHR is more durable compared with transabdominal repair because it permits more accurate intra-operative assessment of esophageal length, greater ease of performing an esophageal lengthening procedure (True Collis), greater ease of closing the hiatus without tension and a better exposure in obese patients.

Shackleford 8e Pg 296.

Question 31

which is the fundoplication preferred when performing a transthoracic PEHR

A. Dor fundoplication
B. Hill repair
C. Belsey Mark IV repair
D. Nissen floppy repair

Answer 31

Ans C -
When an open transthoracic approach is used, the fundoplication that is included in the PEHR is near total 240 degree Belsey Mark IV repair.
This is a 6 suture fundoplication of three sutures per two rows evenly positioned over the 240 degrees of the anterior stomach to cover 4cm of intra-abdominal esophagus.

Shackleford 8e Pg 296

Question 32

all of the following are associated with increased perioperative mortality during PEHR except

A. Age > 50 years
B. Comorbid conditions
C. Emergent procedure
D. Open approach

Answer 32

Ans A

the mortality and morbidity rates are higher in patients who are 70 years or older, who underwent an emergent procedure, had multiple cormorbid conditions or had open transthoracic or transabdominal PEHR.

Shackleford 8e Pg 298.

Patients 80 years or older had higher ASA class, more comorbidities, larger PEHs, and higher incidence of type IV PEH and acute presentation.
They had more post operative complications and hospital stay was 1 day longer.
After adjustment for cormorbidities and other factors, age older than 80 years or older was not a significant factor in predicting severe complications, readmissions within 30 days or early recurrence. Older patients with giant PEHs should be given the opportunity to be evaluated by experienced surgeons for PEHR. Advanced age is no longer a contraindication for PEHR.

Shackleford 8e Pg 298.

Question 33

which of the following statements is not true regarding PEHR

A. Rate of radiographic recurrence is higher than the rate of clinical recurrence

B. Most common form of recurrence is mixed PEH

C. Laparoscopic approaches have higher radiological recurrence rates than open approaches

D. Clinical recurrences can be mostly managed with medical management

Answer 33

ANS B -

The rate of radiographic recurrence is higher than that of clinical recurrence. Most patients with radiographic recurrence after PEHR are asymptomatic, whereas patients with clinical recurrence can usually have symptoms controlled with medications. Only a small percentage of patients will require reoperation for complications or intractable symptoms.

Laparoscopic PEHRs have a higher radiologic recurrence rate than two open approaches, but most of these recurrences are clinically silent and do not require reoperations.

Laparoscopic PEHR - radiographic recurrence of 25% and clinical recurrence of 10%.

The majority of recurrences are sliding hernias less than 2cm in size.

Shackleford 8e Pg 298, 299.

Question 34

what is the definition for high volume centre for PEHR

A. >5 operations per year
B. >10 operations per year
C. >20 operations per year
D. >25 operations per year

Answer 34

Ans C

Hospital surgical volume was categorized as small (<6 operations per year), intermediate (6-20 operations per year) and high as more than 20 operations per year.

Patients undergoing PEHR at high volume centres had fewer postoperative complications and shorter hospital stay and they were more likely to undergo a laparoscopic repair.

Shackleford 8e Pg 299.

Question 35

Which of the following materials is preferred to cover the defect after relaxing incisions in diaphragm during PEHR

A. Polypropylene
B. PTFE
C. Bovine pericardium
D. Composite mesh

Answer 35

Ans B -

the concept of relaxing incision is to create a defect adjacent to the area of interest that is less critical to allow the principal tissues to come together.
But because there is pressure difference between thoracic and abdominal cavities all relaxing incisions must be closed and therefore even small diaphragmatic defects can lead to herniation of abdominal contents into the chest.

PTFE is routinely used to close these defects, since there is a large experience with this mesh for chest wall and diaphragm reconstruction. Unlike other types of synthetic mesh the lung typically does not fuse to the PTFE mesh, so future thoracic surgical procedures if needed will not be made more complex.

Unlike ventral hernia repairs the use of simple interrupted sutures to sew the PTFE mesh to the edges of the defect with no overlap works well on the diaphragm. This is likely possible because as the mesh contraacts the diaphragm has enough give to accomodate without tearing the stitches out. Infact the large amount of shrinkage that occurs with PTFE mesh may be beneficial in restoring a more natural contour to the diaphragm over time after a relaxing incision.

Absorbable and biologic mesh should be avoided since it will not permanently repair the defect, setting the stage for hernia recurrence.

Shackleford 8e Pg 301.

Question 36

The first step to allow crural movement and approximation during PEHR is

A. Creation of left pneumothorax
B. Relaxing incision
C. dissection of posterior sac off of the left crus.
D. None of the above

Answer 36

Ans C -

The first step to allow crural movement and approximation is to ensure that the posterior sac has been well dissected off of the left crus. When the sac remains attached to the left crus, it can restrict movement and reapproximation of the crura. The second step is to create left pneumothorax. The will equilibrate the capnoperitoneum on the both sides allowing the left diaphragm to become floppy and facilitating its movement towards the right crus.

If there is still excessive tension when trying to approximate the crura despite these maneuvres, a relaxing incision is the next recommended step.

Shackleford 8e Pg 301.

Question 37

which of the following statements is true regarding the diaphragmatic relaxing incision in PEHR

A. Left sided incisions are preferred over the right sided incision

B. Left diaphragm is more tendinous compared to the right

C. The heart must lie anterior and medial to the left sided relaxing incision

D. The IVC must lie anterior and medial to the right sided relaxing incision

E. the left sided incision is usually smaller and takes lesser time to repair.

Answer 37

Ans C

Right sided relaxing incision is the preferred release, but the right crus must be atleast a centimeter wide to have enough tissue to reconstruct the hiatus.
Particularly in the setting of reoperations the right crus may be so thin and scarred that there is insufficient room between the edge of the crus and the IVC to do a right sided relaxing incision. In these patients or when the right sided incision alone is insufficient then a left sided relaxing incision is necessary.

It is important that the relaxing incision be made anterior to the apex of the hiatus not posteriorly at the base since the aorta, thoracic duct are near the base.

A right relaxing incision is made by opening the right crus parallel to the IVC saving a 3cm cuff of tissue along the IVC. It is started in the midportion of the right crus and ends at the anterior crural vein. If this is insufficient then the vein can be ligated and the incision carried further anteriorly and medially.
Diaphragm on the right is quite tendinous and therefore the incision can be made using cautery.

The only structure on the right side to avoid injuring is the intra-thoracic vena cava and this should always be anterior and lateral to the incision.

1mm PTFE mesh is sewn on the right side with interrupted 3-0 sutures.

Left sided incision is larger and needs more time to repair. It should be made laterally following the seventh rib. The phrenic nerve is protected on the right side by the vena cava but a radial incision on the left side puts the phrenic nerve at risk.

The only other structure of significance with a left sided relaxing incision is the heart with should be anterior and medial to the site of the incision.

Left pneumothorax should be created prior to starting the left incision.

The incision is started lateral to heart nearly 1-2cm below the seventh rib and carried laterally towards the spleen to allow sufficient release.

The left diaphragm is more muscular and therefore the incision made with ultrasonic devices.
2mm pTFE is sewn in with 0-Ethibond sutures.

No drains were left in the pleural space or mediastinum and no patient developed pleural effusion prior to discharge.

Shackleford 8e Pg 302, 303.

Question 38

All of the following are risk factors for shortened esophagus except -

A. Advanced GERD with esophagitis, stricture or Long segment BE
B. sarcoidosis
C. Caustic ingestion
D. Scleroderma
E. None of the above

Answer 38

Ans E

Patients at risk for acquired esophageal shortening include those with -

• advanced GERD with esophagitis, Stricture, Long segment BE.
• history of sarcoidosis
• history of caustic ingestion
• history of scleroderma
• large sliding or paraesophageal hernia

in some reports patients with PEH have the highest frequency of a short esophagus.
The presence of both a large hiatal hernia (>5cm) and an esophageal stricture further increases the risk of shortened esophagus.

A history of previously failed anti-reflux procedure with recurrent hiatal hernia should raise suspicion that length of the esophagus is short.

The etiology of esophageal shortening in patients with a PEH is unclear, but may be related to loss of elasticity in the longitudinal esophageal muscle related to chronic loss of intra-abdominal fixation of the GEJ.

Shackleford 8e Pg 305.

Question 39

which of the following statements is true regarding shortened esophagus?

A. Can be effectively ruled out if hiatal hernia fully reduces on a barium esophagogram
B. Objective studies can rule out a short esophagus
C. No objective studies can confirm the presence of shortened esophagus
D. All of the above.

Answer 39

Ans D -

A foreshortened esophagus can be effectively ruled out when a hiatal hernia fully reduces on barium esophagogram

But in any non-reducing hiatal hernia a short esophagus may or may not be present.

Therefore, although objective studies can rule out a shortened esophagus, none can accurately identify its presence.
It can only be confirmed by intra-operative inability to reduce the GEJ below the hiatus by 2-3 cm after mediastinal esophageal mobilisation and posterior crural closure.

Shackleford 8e Pg 305.

Question 40

which of the following statements is false regarding shortened esophagus?

A. the length of intra-abdomninal esophagus should be 2-3cm
B. Mediastinal dissection and posterior crural closure are routinely used to add esophageal length
C. The length of intra-abdominal esophagus is laparoscopic appears to be less than the actual intra-abdomninal length.
D. esophageal lengthening is recommended if standard methods of esophageal mobilisation fail.

Answer 40

Ans C -

Failure to obtain the adequate length of intra-abdominal esophagus is a leading cause of reherniation and breakdown of repair.

Mediastinal mobilisation and posterior crural closure, paritcularly in a kyphotic patient are routinely used to add esophageal length.

To accomplish a fundoplication without tension there should be 2-3 cm of intra-abdominal esophagus below the hiatal closure.

The amount of intra-abdominal esophagus during laparoscopic surgery is deceptive because the pneumoperitoneum artificially elevates the diaphragm and gives the appearance of more esophageal length than is actually present. When deflation of the pneumoperitoneum occurs, the diaphragm descends and some of the apparent intra-abdominal esophageal length is lost.

Shackleford 8e Pg 305.

Question 41

Which of the following is a true statement regarding Collis Gastroplasty

A. The fundoplication should be done as high on the gastroplasty as possible.

B. The gastroplasty tube is aperistaltic

C. Partial fundoplication or Nissen fundoplication is done in all patients

D. All of the above

Answer 41

Ans D

The staple line of the gastroplasty is not reinforced but rather buried by the fundoplication.

A partial Toupet or complete Nissen fundoplication was added to the Wedge Fundectomy Collis Gastroplasty in all patients.

The fundoplication was kept as high on the gastroplasty as possible, preferably at the top near the GEJ. The importance of this is the fact that the gastroplasty is made from stomach and acid production by the gastroplasty above the fundoplication can lead to erosive esophagitis in some patients, particularly if there are several centimeters of gastroplasty above the fundoplication.

It is also important to recognize that the gastroplasty tube is aperistaltic. Therefore bolus transport through the gastroplasty relies on the motility of the distal esophagus above the gastroplasty.

Shackleford 8e Pg 306.

Question 42

which of the following statements is false regarding use of mesh during hiatal hernia repair

A. Mesh use is associated with a decreased recurrence rate in the short term

B. QOL is significantly improved with Mesh used when compared to without mesh

C. Reoperation with mesh in place is tedious and may even require esophago-gastric resection.

D. Routine use of mesh cannot be justified,

Answer 42

Ans B -

Most studies report a short term higher reccurence rate of hiatal hernia when it has been repaired without mesh. Only one study has produced long term data on the use of bio-absorbable mesh and that study reports equally alarmingly high rates of recurrence of HH both with and without the use of mesh.

There is a significant improvement in the QOL parameters both with and without mesh reinforcement. A findings which may not be associated with endoscopic or radiographic recurrence.

Although mesh reinforcement at the hiatus seems to lessen the likelihood of short term radiographic recurrence, no evidence shows that this is still the case at longer term follow up.
Reoperation when mesh has been used previously (regardless of mesh composition) is in the least case tedious, and in the worst case hazardous - commonly leading to the need for esophagogastrectomy.

The routine use of mesh cannot be justified at present, and its use should be restricted to individual cases based on the treating surgeon’s discretion and based on the intra-operative findings.

Shackleford 8e Pg 312.