Laparoscopic Nissen procedure for voluminous hiatal hernia with large hiatal defect

This video demonstrates a laproscopic repair of type II paraesophageal hernia. The surgeon demonstrates the approach to dissection and resection of the hernia sac and reduction of the sac and esophagus into the abdomen. The defect in the hiatus is closed with pledgets and a routine floppy Nissen is constructed with three sutures.

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Laparoscopic Nissen procedure for voluminous hiatal hernia with large hiatal defect

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Abstract

This video demonstrates a laproscopic repair of type II paraesophageal hernia. The surgeon demonstrates the approach to dissection and resection of the hernia sac and reduction of the sac and esophagus into the abdomen. The defect in the hiatus is closed with pledgets and a routine floppy Nissen is constructed with three sutures.

Classification

complex cases

Keywords

laparoscopic,gastroesophageal reflux disease,paraesophageal hernia

Media type

Surgical video

Duration

21'00''

Publication

2004-12

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E-publication

WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1579.htm

Laparoscopic Nissen procedure for voluminous hiatal hernia with large hiatal defect

1. Trocar placement 00'14''

This patient has a giant hiatal hernia, the port placement is exactly the same as we did for the first operation, the view inside is a little different.

2. Exploration and exposure 00'38''

This is a male patient (our previous patient was female) so that in terms of anatomy, it is a little different. Besides that we have here a very huge hiatal hernia because you see that we have a large piece of the stomach in the chest. The strategy is different from the previous operation, as you can see a very large cavity within the mediastinum. I can’t approach the phreno-esophageal membrane because there is none, initially there are 2 options to approach these hernias, first to work within the sac but it was very difficult and very dangerous so we have to privilege an outside approach; we are working outside the sac to reduce it progressively within the abdomen, then the esophagus and the GE junction follow in this reduction of the sac because if I try to reduce, it goes back immediately. We are going to work on this part of the hiatus and we are going to start reducing the sac by beginning on the right crus.

3. Hernia sac dissection 03'08''

I am trying to find a plane. As soon as you get this, reduction of the sac is becoming easier, you see very strong attachments. It is important to go very low. I think that we are good in this plane. I am going up into the mediastinum and you see the sac is coming easily. It is really important to work outside the sac.

4. Esophageal mobilization 05'19''

The next step will be to try and identify the esophagus because up to now, we don’t know where it is but by reducing the sac, you can see that immediately probably the esophagus is lying somewhere here. We are still on the edge of the crura, but we have a little bit of fat. This is becoming safer and safer because we have all the important structures in the operative field. The important thing is that you have to deal with all this fat so you just need to take your time to present the structures properly. There are still some fixations on the base of the right crus. This is quite typical with this fatty tissue, at the top of the sac, it’s a lipoma. Now I am looking a little bit more to see where my left crus is, no vagus trunk in the area. I have a way but I try to free a little bit more here all those adhesions between the sac. My assistant and I are adapting our movements in order to deal with these fatty tissues, as soon as I release some fatty tissue, he holds back the camera. There are still some fixations there, this is the pleura, very thin. It is not usual to see this vein that well; when you see that, you can imagine that it can be a dangerous operation. That is the reason why we have to progress step by step, landmark by landmark and not try to make it quicker or use shortcuts because it is so important. Progressively everything is coming down, the problem with these giant hernias is the question about the length of the esophagus. Probably in this type of young patient, I would care about the length. So we are doing the same on the other side, the vagus trunk is there. I think I will try to get my junction on the drain to be able to give very important traction and to reduce progressively those periesophageal lipomas. You saw beforehand that I found my way here, I am very cautious there because I don’t know exactly where the vagus trunk is. You see this posterior window here with a lot of fat, we see the diaphragm on the other side. I am using this tape to hold the junction, you see this lipoma; it is like in the inguinal hernia in fact. We will continue to mobilize, we have now a good traction on the esophagus so laterally we know where we are. Just by moving the traction on the drain, we change the view that we can get through the mediastinum. That explains why we can do esophagectomies through the hiatus using the scope. We can go very high up to the carena. Here I have to mobilize a lot. I am not that sure that dividing the trunks would cause that many problems. You see that with all those little steps, we are progressively reducing the esophagus within the abdomen. There is the vagus trunk, I am free to divide this a little more. The big question that will come is how to repair this hiatus. What I want to do now is to dissect this sac because I want to see the exact anatomy of this GE junction. By now I don’t know, I put a drain there but there is still a lipoma, I am not sure exactly where the stomach or the esophagus are. I prefer to divide this sac, if necessary I mobilize the short gastrics in order to help in seeing the true anatomy. Having the GE junction in the abdomen, it’s very important for those patients presenting with true symptoms of reflux. I am starting to see a little bit more. Here is the gastric fundus, the angle of His is there, so I’m continuing to free this sac because I feel more comfortable to see the anatomy. We go back to the drain and you see that we’re getting a little bit more length but there is still some lipoma at the back here, they are the most annoying ones because you don’t know where you are. We mobilize the gastric fundus a little more to see what it looks like.

5. Fundus mobilization 15'02''

I will remove that because it is not very helpful. You see the fundus is not that large,

6. Hiatus repair 15'29''

we are going to do this crura repair. I have got some Teflon pledgets, these are the ones used by the vascular surgeons. I put one here, the other one there, that is supposed to avoid the rupture of the muscle with all the sutures and tension. If at this stage you want to introduce another grasper because you can’t get a good view, putting a 5mm port in the abdomen does not change the outcome for the patient. The goal is not the size of the scar. Take your time to make sure that you’re doing a good job. I am tailoring a little bit my pledgets, it is not necessary to leave too much length. Posteriorly it looks ok, if I do more posteriorly I will have triangulation of the esophagus so I will probably do a closure with one stitch here. The axis of the esophagus is quite well respected, with one more it would probably do that so I prefer to do an anterior one. I am trying to get some peritoneum there because it is a little stronger than simple muscle. The size of the esophagus looks good, I don’t have too much contact between my Teflon and the esophagus because my valve will come here.

7. Fundoplication 19'18''

In patients like this, quite young with huge hiatal hernias, you don’t have a gastric fundus. So that is the reason why I mentioned initially that sometimes it is preferable to do a partial valve; if you can do a very floppy Nissen, it is preferable to do a partial one.