Paraesophageal Hernia Repair

Question 1

What is the most common acquired diaphragmatic hernia?

Answer 1

Hiatal hernia.

Question 2

What structural changes are associated with a hiatal hernia?

Answer 2

Widening of the esophageal hiatus and weakening of the phrenoesophageal ligament.

Question 3

What symptoms suggest the presence of a larger paraesophageal hernia?

Answer 3

Abdominal pain after eating, anemia, and partial organo-axial volvulus of the stomach.

Question 4

What type of hiatal hernia is the most common?

Answer 4

Type I hiatal hernia, accounting for 90% to 95% of all hernias.

Presents with GERD

Question 5

What are the additional symptoms often seen with type II, III, and IV paraesophageal hernias?

Answer 5

Early satiety
anemia
postprandial abdominal or chest pain
vomiting, dysphagia, and weight loss

Question 6

What is the defining characteristic of a Type I paraesophageal hernia?

Answer 6

The esophagogastric junction (EGJ) herniates above the diaphragm into the mediastinum

“sliding hernia.”

Question 7

How is a Type II paraesophageal hernia classified?

Answer 7

A portion of the stomach herniates into the mediastinum alongside a normally positioned (intraabdominal) EGJ.

Question 8

What is the defining feature of a Type III paraesophageal hernia?

Answer 8

The EGJ is above the hiatus, and a portion of the stomach is folded alongside the esophagus.

Question 9

What distinguishes a Type IV paraesophageal hernia from other types?

Answer 9

An intraabdominal organ other than the stomach also herniates through the hiatus.

Question 10

What factors determine the indication for surgery in patients with a paraesophageal hernia?

Answer 10

The severity of the patient’s symptoms and their other comorbid medical conditions.

Question 11

When might patients with a paraesophageal hernia be managed without surgery?

Answer 11

When their symptoms are well controlled on acid suppression medications, and they do not have dysphagia, weight loss, or pain.

Question 12

What imaging studies are commonly used to evaluate paraesophageal hernias?

Answer 12

Contrast esophagram and computed tomography (CT) scan.

Question 13

Why is upper endoscopy important in the evaluation of paraesophageal hernia patients?

Answer 13

To determine the presence of esophagitis, gastritis, Cameron ulcers, peptic ulcer disease, and to rule out malignancy

Question 14

What role does esophageal manometry play in the management of type I and type II paraesophageal hernias?

Answer 14

It assesses esophageal motility to guide the decision for the appropriate fundoplication during hernia repair.

Question 15

Why is esophageal manometry difficult to perform in patients with large type III or type IV paraesophageal hernias?

Answer 15

The catheters often curl in the esophagus or herniated stomach, limiting the accuracy of the data.

So you Do Partial Fundo for them

Question 16

In which patients is pH testing critically important

Answer 16

In patients with significant symptoms of gastroesophageal reflux disease (GERD) without the presence of a paraesophageal hernia.

Question 17

Which types of paraesophageal hernias are almost always successfully repaired using the laparoscopic technique?

Answer 17

Type I and type II paraesophageal hernias.

Question 18

What are the advantages of laparoscopic repair of type I and II paraesophageal hernias?

Answer 18

It is associated with decreased operative morbidity compared to thoracotomy

Question 19

What complications may arise during the laparoscopic repair of large type III and IV paraesophageal hernias?

Answer 19

Pneumothorax and loss of pneumoperitoneum due to adhesions between the hernia sac and structures like the pericardium, lung, and airway.

Question 20

Why might open repair be preferred for large paraesophageal hernias?

Answer 20

Open repair provides better visualization, especially for structures above the level of the inferior pulmonary veins.

Question 21

What are some relative indications for open repair rather than laparoscopic repair of paraesophageal hernias

Answer 21

Previous paraesophageal hernia repair
extension into pleural spaces
and proximal extension to the level of the carina.

Question 22

Laparoscopic Repair of Paraesophageal Hernias (Hernia Sac)

Answer 22

-NGT Decompress Stomach
-Supine Position
-5 Ports ( Camera,2 for Surgeon,1 Assistant,1 Liver)
-Camera Medline 14 cm Below Xiphoid
-Open Gastrohepatic Ligament
-Attention to a replaced or accessory left hepatic artery.
-periesophageal tissues are then dissected
-anterior and posterior vagus nerves are identified.
-dissect the sac away from the pericardium
-hernia sac is then dissected away from the left crus
-expose the posterior aspect of right and left crura
-The posterior dissection is completed allowing the herniated stomach and the hernia sac to be reduced into the abdomen
-mobilize the greater curvature of the stomach, dividing all short gastric vessels
-removing the entire hernia sac often results in small tears in the pleura, creating capnothorax with associated hypotension or increased airway pressure

Question 23

Laparoscopic Repair of Paraesophageal Hernias (Mobilize Esophagus)

Answer 23

-mediastinal dissection is extended proximally by dividing the small esophageal arterial branches
-Dissection is continued up into the mediastinum to achieve at least 3 cm of intraabdominal esophagus
-It is quite helpful to decrease the insufflation from 15 mm Hg to 8 mm Hg
-Interrupted 0 Ethibond sutures reapproximate the posterior right and left crura just above the aorta
-both the aorta and inferior vena cava are in close proximity to the posterior crura.
-Before the last crural sutures are tied, a 52F or 56F bougie is carefully inserted down the esophagus, and there should be room for a closed grasper to easily slide between the esophagus and crura.

Question 24

the use of biologic mesh for reinforcement of the crural closure ?

Answer 24

long-term recurrence rates are similar between cruroplasty alone versus cruroplasty with biologic mesh.

However, the overall morbidity seems to be higher in patients repaired with nonabsorbable mesh.

Question 25

Creation of the Fundoplication

Answer 25

-56F bougie remains in the lumen of the esophagus
-Fundus of the stomach is passed behind the esophagus
-three 2-0 Ethibond sutures are used to create the Nissen fundoplication
-Each stitch is placed through the seromuscular wall of the stomach on the left side of the fundus, the muscular wall of the esophagus, and the right side of the fundus at 1-cm intervals
-the anterior portion of the fundoplication should be approximately 2 cm in length and should sit comfortably below the hiatus
-place sutures between the superior aspect of the wrap and the right and left sides of the crural closure, creating a gastropexy to anchor the wrap below the hiatus

Question 26

When the patient’s esophageal motility will not allow a Nissen fundoplication

Answer 26

-Toupet fundoplication (posterior 240-degree fundoplication) is created

-total of six 2-0 Ethibond sutures.
-Three are placed through the seromuscular right and left sides of the fundus and are separately sutured to the right and left sides of the muscular wall of the esophagus,
-leaving 120 degrees of the anterior esophageal wall uncovered

Question 27

Open Repair Vs Lap for Large Hernia

Answer 27

large paraesophageal hernias (type III and type IV) and reoperative paraesophageal hernias using

lap and/ or a combination of lap and VATS techniques :

-operative times are longer
-and the risk for complications such as gastric or esophageal perforation

Question 28

How to create esophageal lengthening

Answer 28

Collis gastroplasty or a fundic wedge gastroplasty

Question 29

What type of Fundo to do with Esophageal lengthening ?

Answer 29

A Toupet fundoplication is performed (instead of a Nissen fundoplication) to prevent postoperative dysphagia.

Question 30

Post Op Care

Answer 30

-NGT for Type 3-4
-No need NGT for Type 1-2

-Contrast esophagogram day 1 > asses gastric emptying
-discharge on full liquid diet
-follow up after 2 weeks