Laparoscopic treatment of a recurrent hiatal hernia with mesh reinforcement of the crura

This video demonstrates a complex case of recurrent hiatal hernia in a patient with previous open repair. The surgeon demonstrates safe mediastinal mobilization of the esophagus and the stomach and full reduction of hernia sac and contents. Due to the size of diaphragmatic defect, the crural repair is reinforced with a piece of composite mesh. No fundoplication is carried out. This video is a good demonstration of approach to revisional hiatal hernia surgery and is suitable for surgeons with experience in laparoscopic fundoplication who are now considering revisional surgery.

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Laparoscopic treatment of a recurrent hiatal hernia with mesh reinforcement of the crura

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Abstract

This video demonstrates a complex case of recurrent hiatal hernia in a patient with previous open repair. The surgeon demonstrates safe mediastinal mobilization of the esophagus and the stomach and full reduction of hernia sac and contents. Due to the size of diaphragmatic defect, the crural repair is reinforced with a piece of composite mesh. No fundoplication is carried out.
This video is a good demonstration of approach to revisional hiatal hernia surgery and is suitable for surgeons with experience in laparoscopic fundoplication who are now considering revisional surgery.

Classification

complex cases

Keywords

recurrent hiatal hernia, mediastinal mobilization of esophagus, hiatal repair with mesh,RGO,Nissen,oesophage court,extensive dissection

Media type

Surgical video

Duration

20'00''

Publication

2006-01

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E-publication

WeBSurg.com, Jan 2006;6(01).
URL: http://www.websurg.com/doi-vd01en1882.htm

Laparoscopic treatment of a recurrent hiatal hernia with mesh reinforcement of the crura

1. Trocar placement 00'18''

This patient has an incisional hernia and we enter the abdomen through the left hypochondrium with a 10mm port and now we’re using this port in order to get access to the midline. I’ve some trouble finding the correct positioning of the ports because I have adhesions into the abdomen. I’m trying to find a way and I’m coming with a port from the right hypochondrium and I will try to make a window somewhere. The objective is to get access to the left hypochondrium of the patient in order to place another port that I can use to clear the midline. I’m using a zero degree scope. Using a 30 degree scope in this case of adhesions would certainly be easier to free adhesions. I’m now coming from the midline. We have now an outside view and we see exactly where you are.

2. Adhesiolysis and exposure of hiatal region 02'00''

I’m now working in a more physiological position. We can see the left liver lobe. I will clear a little bit more the adhesions to feel more comfortable and without adhesions that will interfere with the optic. I want to obtain a large view of the hiatus. You see clips there. This is the left hepatic artery. Here is the crus and we have the liver above the right crus. So you see the hiatus is totally open. We have to mobilize the stomach from there and go up into the chest. This hiatus is fixed and we won’t be able to restore it to its normal size so I don’t know yet if we can do an anterior plasty with prosthesis or something of the kind.

3. Hernia content mobilization 04'34''

Let’s move on the stomach. Again I’m working outside of the hiatus in order to find a normal plane. Take your time doing so. You see the stomach is in the chest so I work a little bit like for a large hernia and I’m trying to work really on the edge of the crura. There are quite a lot of clips there. Do you think that a partial opening of the mediastinal crura can sometimes explain postoperative attraction? I don’t think so. Initially when people were looking for the causes of migration, they mentioned this idea of opening the left pleura but really technically and mechanically I don’t understand the way it would explain this occurrence. To find the pleura in this operative field is uneasy. This might be the pleura. Zoom back to get a clearer view of the anatomy. This is the place of this huge hernia. The aorta is there so it creates a big pouch there on the left chest. The esophagus is on the right side of the patient. Caution is required when dissecting this area. Again we’ll work on the right crus. This might be the esophagus. At this stage, I’m not really caring for the vagus trunk. I’m really deep in the chest trying to mobilize all that because it is still fixed. It is a huge defect. This is probably the pleura.

4. Mobilization of esophagus 12'50''

I’ll cut this. Is this the vagus trunk? Here we can clearly see the left border of the esophagus. This is the vagus trunk since I can find the natural plane here. If the valve is in a proper position, if this is a valve and we can imagine the GE junction is on there, the valve is well placed, I won’t do anything on the valve.

5. Hiatus preparation 14'12''

Now we’ll wait for the endoscopist. We’ll prepare the hiatus. We’re looking for the left crus. Here’s the spleen. We’ll check the fundoplication.

6. Hiatus repair 16'08''

7. Mesh reinforcement 16'58''

What we’ve done is to close the crura with stitches but you see the muscles are very weak, and mostly the left crus. I’ve decided to reinforce this crural repair with a composite mesh. The mesh, which is polypropylene there and the covering surface on the other side. It was a mesh that was used for an incisional hernia. It’s a polyester one. You see the prosthesis there lies on the spleen. I think it’s a way to reinforce that and it’s necessary in the present case.