Upper Gastrointestinal

Question 1

Steps: Lap Paraesophageal Hernia Repair

Answer 1

1. Gentle reduction of herniated intra-abdominal contents as able
2. Dissection of the hernia sac along the inner border of the crura
3. Identification of the anterior and posterior vagus nerves
4. Circumferential control of the distal esophagus and vagus nerves with a penrose drain
5. Careful mediastinal dissection for complete hernia reduction including 3 cm of intra-abdominal esophagus
6. Division of the short gastric vessels if performing fundoplication
7. Closure of the crural defect with nonabsorbable pledgeted sutures
8. Fundoplication or gastropexy

Question 2

Pitfalls: Lap Paraesophageal Hernia Repair

Answer 2

• Pneumothorax during mediastinal dissection if the pleural edges are not recognized and reflected laterally
• Injury to the anterior or posterior vagus nerves; these should be contained within the penrose drain and particular caution used during dissection and division of the anterior and posterior hernia sac
• Undue traction on the stomach can result in serosal tears
• Esophageal injury can occur during mechanical dissection or from heat injury 2/2 inappropriate use of energy