You need to log in to watch this media!

Click here to log in.

Laparoscopic repair of a giant hiatal hernia: challenging dissection of the hernia sac

Authors

B Dallemagne, J Marescaux

Abstract

This live operative recording shows the laparoscopic performance of a giant hiatal hernia repair.

Keywords

laparoscopy, repair, giant hiatal hernia, dissection, hernia sac

Media type

Duration

17'54''

Publication

2008-05

Popular

Favorites

Audio

Subtitles

E-publication

WeBSurg.com, May 2008;8(05).
URL: http://www.websurg.com/doi-vd01en2328.htm

Laparoscopic repair of a giant hiatal hernia: challenging dissection of the hernia sac

1. Trocar placement 00'22''

I will place the trocar a little bit higher on the abdomen because of this very huge hiatal hernia and I know I’ll have to work very high in the chest. Sometimes a 30 degree scope might be helpful when you have some trouble into the mediastinum but to start with I prefer to use a zero degree scope. We are watching put a liver retractor because some people may not be familiar with it. This is the 5mm liver retractor and by turning the screw, you pre-form this system. It is very atraumatic for the liver. Usually when you have this fan-like retractor, sometimes you can injure the liver.

2. Operation commences with reduction of hernia and demonstration of anatomy 01'18''

You see this is the stomach, which is probably within the mediastinum, what we call the “upside down” stomach with an axial rotation, see. You can imagine that this bubble within the chest can create some trouble. You see the hole is huge. You can imagine that the esophagus is somewhere here, this is the aorta. That’s very dangerous to go straight. The probe, the nasogastric tube is coming. On the other hand, you see that all the lesser omentum went up into the mediastinum so in this condition, it’s almost impossible to say we’ll keep the branches and unfortunately in this patient there is a left hepatic artery and I have to divide it. Are there any advantages starting on the left side?

3. Dissection of hiatal hernial sac 02'20''

Yes, because usually the big fixation of the sac is on the left crus. We’ll see that we can have a very strong attachment of the sac on the left crus. I’m trying to work outside of the sac. In this patient, it’s not GERD but a problem of huge mediastinal sac and stomach and all related problems. I’m trying to find the plane, which is a little bit easier on the left side. It’s essential to take the sac out though. Indeed. We’re just trying to get the plane between the crus and the sac. We have to apply very gentle traction because I can perforate very easily so I try to find another plane. This sac is very thin, which is unusual. We now go on the left. Usually when you have some trouble to get the plane, you’re going back in this direction. It’s often thicker there. I’ll try to do that with another grasper and see if I can get into the cleavage plane. As Dr. Swanström mentioned, it has to be blunt because it’s an avascular plane. I’m trying to find another plane otherwise I can’t get it. So I try on the other side, maybe I’ll find another plane on the right side, which is quite unusual but I have to try it. It looks a little bit stronger on this side. It seems like a good plane now. With the CO2, there is some bubble within the sac and it helps in finding the right plane. As soon as I reduce this part, I’ll get access to the esophagus. It’s essential at this point to know where the esophagus is. Here we see the tip of the sac and I’m just reducing as for an inguinal hernia. Sometimes you have a posterior fixation there. It’s essential for me to know where I am regarding the position of the esophagus. The big risk of course is to injure the esophagus. The size of the sac is enormous. We have the esophagus there very high. I can imagine that the anterior vagus trunk is in this direction. I think it’s over there. These are attachments of the sac. The fact that I’m keeping the sac intact initially is just to know about the anatomy. Even from the X-ray, you can’t predict if it’s going to be easier or not. What I can do is to open the lesser omentum a little bit more and to compensate for the lack of angulation of the scope. I’ll work from below. The hepatic artery is now in a more convenient spot. We saved the artery so we can work in this window. This is my crus probably. So you see the landmarks, right and left, in the same way as for reflux.

4. Taping of esophagus for retraction 07'52''

Again we use the umbilical tape on the other side. We have the big challenge to take up with this sort of hernia is to get our segment of esophagus into the abdomen. The spine is right there. That’s the trunk and you see how fixed is the esophagus; as soon as we divide this trunk attachment, we can feel the esophagus is coming back. Now we will work on the sac. The idea being if I open this sac, I’ll have a clearer view on the GE junction so if I want to play some anti-reflux mechanism, it’ll be easier. Is there still a need to manipulate the short vessels? The gastric fundus is loose. Is it necessary to cut the short vessels or just take the flap? Sometimes it is not necessary so I’ll check afterwards if the fundus is coming easily or not. Usually in the vast majority of people, when I’m adding a Nissen or like in young patients, I’m mobilizing the short gastrics. I’m doing exactly the same valve as for reflux. But in all patients, I’m adapting the technique a bit. You’ll do a posterior closure, is that correct or would you do an anterior one? Both, this patient will try to do some physical exercise tomorrow morning. How do you know?

5. Crural repair (with pledgets) 10'58''

We now try to do the crural repair. Do you see this PTFE tissue? That’s the original size and I’m trimming these little bands and apply that on both crura, external side, and then we’ll reinforce the suture and we’ll avoid division of the muscle. There you’d have a nice advantage with a 30 degree scope but I manage alright without it. Initially a few years ago when we were able to re-use some prostheses, I was used to taking parts of vascular prostheses and their shape were nice because you were cutting them into 2 pieces and got a nice curved prosthesis that you could plug on the crura. It’s the only time when I do extracorporeal ties because it’s under so much tension. So usually the space for the suture is above the liver. Pay attention here not to cut the suture. So I prefer that to a mesh. So now remember Dr. Bailey’s trick. Is there a tube in the esophagus, it just looks like it. There was one, we can remove it. You don’t feel it in this case of huge hernias; you saw that at the start of the operation, we couldn’t deflate the stomach and now because we have reduced the hernia, we don’t have the stomach any more. Do you see the difference? In these conditions, I keep the tube because it decompresses the stomach when you reduce the hernia.

6. Creation of partial posterior fundoplication 15'00''

Probably I’ll use a partial posterior approach. You see the short gastrics stretched out. Do you see the difference even with these long short gastrics where everything is going back to the spleen as compared to the Nissen that we’ve made this morning when everything was staying nicely in place? What would you do now? Total or partial? Total! I won’t do it myself. I’ll do a partial not because you think the patient is at risk of getting dysphagia but because I know the motility. Here’s the last suture on the left side of the esophagus and we’ll be done.

7. Completed procedure 17'20''

This is the final view so we have our crural repair. We’ve seen that the esophagus is not in contact with the pledgets. Anterior repair. You see this partial posterior fundoplication on both sides and I’m done. I’ll do my knot. And you see that the stomach is in the right position.

Username
Password
	Remember me (needs cookies)