Paraesophageal herniation of the colon: laparoscopic repair

Large paraesophageal hernias (PEHs) occur most commonly in an elderly, debilitated patient population with existing co-morbid conditions. The surgical approach to paraesophageal hernias (PEHs) has changed with the advent of laparoscopic techniques. This video presents the case of a 72-year-old male patient referred to our unit for epigastric pain. In this patient, the endoscopy showed nothing specific concerning this pain. The barium swallow showed no abnormality, but just a lateralization of the esophagus. The CT-scan demonstrated a large hiatal hernia. The laparoscopic repair is presented here.

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Paraesophageal   herniation   of   the   colon:   laparoscopic   repair

Authors
B Dallemagne, S Perretta, J Marescaux
Abstract
Large paraesophageal hernias (PEHs) occur most commonly in an elderly, debilitated patient population with existing co-morbid conditions. The surgical approach to paraesophageal hernias (PEHs) has changed with the advent of laparoscopic techniques. This video presents the case of a 72-year-old male patient referred to our unit for epigastric pain. In this patient, the endoscopy showed nothing specific concerning this pain. The barium swallow showed no abnormality, but just a lateralization of the esophagus. The CT-scan demonstrated a large hiatal hernia. The laparoscopic repair is presented here.
Classification
complex cases
Keywords
Paraesophageal herniation of colon, laparoscopic repair
Media type
Duration
28'40''
Publication
2009-07
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Jul 2009;9(07).
URL: http://www.websurg.com/doi-vd01en2610.htm

Paraesophageal   herniation   of   the   colon:   laparoscopic   repair

1. Clinical case presentation 00'18''
It is a patient who was born in 1937. He presents with epigastric pain. In this patient, the endoscopy showed nothing specific concerning this pain. This patient had a barium swallow, which showed no abnormality. We just saw a lateralization of the esophagus and that’s the 2 images we have. This patient then had a CT-scan and when we go down, we immediately see a large hiatal hernia. The paradox is that in this patient we identify this as the colon, so with a lot of omentum. Therefore it is a patient who presents with a large hiatal hernia. The stomach is well in place and the hiatal hernia is filled with the colon and the omentum. Now we are going to see what the intraoperative aspects are. This patient has no medical history. Just a few months ago, he had an episode of epigastric pain and dysphagia. He could not eat or swallow water and he went immediately to the endoscopist who saw nothing in the esophagus, besides some lifting of the esophagus by something coming from outside the esophagus. The GE junction looks in the right position. This patient had a CT-scan as you can observe on the screen. Here you have the view of the abdomen. You can see the umbilicus. We are working above the umbilicus with on the lateral side the liver retractor, on the left lateral side, a trocar that will be used by the assistant and the surgeon will work with the 2 main trocars in the medial part. In this patient, we use a 30 degree scope because we don’t know exactly what we will find. The hypothesis is that it is a paraesophageal hernia not containing the stomach but the colon.
4. Freeing of colon 04'29''
I’m working mostly on the meso, not touching the colon. And everything is coming quite nicely in fact. I don’t know if I can reduce that. You see that as soon as we are manipulating, we induce some oozing so probably I’ll try to get access from the lateral side of the crus. So I’ll start my dissection on the side just for a typical hernia. Because I want to know exactly what happens in the mediastinum, so if I can get some view on the mediastinum, that should be nice. See it’s not like a hiatal hernia when you find a sac. But apparently there is no sac or we’ll see if there’s one. This is the colon coming. I’m sure that as soon as I’ll get the colon out of it, it’ll come easily. The trick sometimes is to reduce the omentum first. That’s right. I don’t like traction on the colon so that’s why I’m retracting. It’s voluminous. Looking back on the medical history, we can find ideas of trauma or something of the kind. But there was none, no car accident, nothing that would allow us to think there’s a traumatic issue. But there should be some factor accounting for this huge migration and probably this is a hole in the phrenoesophageal ligament. I think that we got it. See it’s just a side of the esophagus, there’s a big sac or a big cavity, no sac in fact, because you see we are inside the mediastinum but apparently there’s no hernia sac, the same as for the hiatal hernia. So this is probably a little breach into the phrenoesophageal ligament that leads to this massive herniation. My problem is really this colon that wants to go back immediately to the mediastinum so I need to find some way to hold it like this. There are probably some adhesions on the crura that still fix the colon in this position. So now the problem is I don’t know where my GI tract is so I’m looking for the left crus in fact. So I think my left crus should be somewhere around there. I can see that there is some stomach.
5. Left crus identification 08'00''
At this point, I’m looking for the left crus. It looks like a crural structure here. So probably the esophagus is just next to that if I’m right. So I’ll change a little bit the way I’m retracting. It’s a big lipoma. It looks like it. So I’m controlling the left crus with my hand. I’m following the orientation of the crus. We have a lot of things inside. We have to look for the pleura. The hiatus is larger than we thought at the beginning. That’s right. This is the esophagus. So probably there are lots of adhesions with the pleura. This is the vagus trunk. So in fact I’m trying to get my normal plane so I’ll look a little bit higher because probably I can find… See the limit of the pleura there. It’s very clear indeed. Working like this, the idea is to create the cleavage plane and then as soon as you have identified the different structures, then only then come with a cutting device. I don’t know if I have a cleavage plane, you see between this sac and the esophagus. And there is a sac. So that’s probably the edge of the sac. And do you always need to remove such a sac or not? I think so because usually it should come very easily. Sometimes it comes like a regular hernia sac so in such conditions you may consider to remove it. There’s a big vein there. So you see the sac is coming quite easily. In the mediastinum that can create a big seroma and dysphagia. There we have the normal mediastinal structures. The pleura is on my left hand. It looks like a paraesophageal hernia with a sac. But I don’t know why it’s the colon that went inside and not the stomach. So the pleural cul-de-sac should be somewhere there. See I’m seeing the origin of my left crus so I’m looking for the beginning see, the left crus is there. I have everything outside. So that’s a very good landmark. So there’s a good trick to find the posterior way in this sort of complex operation. And you see just following my left crus. Probably I’ll find my way there. So that’s a good trick for this sort of hernia for anti-reflux surgery. It’s always very helpful. So we’re restoring this sort of normal anatomy. So now you see I have my window there. I’ll put a drain. Do you think that the GE junction was in the right position because there was no reflux if I remember well? I think so because it was really stuck on the left crus so probably at the right level. It’s true that we have to absolutely remove this pericardial lipoma because we can’t first easily identify the right position of the junction, and secondly if we are considering some anti-reflux mechanism, we can’t place the valve see. Could you imagine putting your valve just around this? You are always going straight ahead to big problems in terms of dysphagia. The funny thing is that we did not see any stomach yet. The sac is here. I feel more comfortable and there’s still a band here. So we don’t need a colorectal surgeon. I can still go ahead. I’m just checking if this is the stomach or not. Because usually this big lipoma is on the top of the gastric fundus and you have to find the exact limit. There are probably some residual bands from this herniation.
6. Upper gastric fundus mobilization 15'13''
To recreate a little bit the anatomy, I will just mobilize a little bit of the upper gastric fundus to be sure of the anatomy and the upper part of the fundus. I will start the mobilization at this point. So then I will have a quite good view on the top of the gastric fundus, and in order to be sure that all the anatomy is in the proper position, it’s quite interesting. You see this is the grasper coming from the left side from the assistant, now he will open the rear cavity like this. The fundus is coming in my left hand. See my left hand is lifting up the fundus progressively and I just check if there are other attachments. You see that during all this part I did not look at my spleen. I am not looking for the spleen because, like in open surgery, if you look for the spleen you injure it. We are ready for a fundoplication if we want, that is really the fundus that we are mobilizing, not the stomach; you see that all the stomach is intact so it’s really the upper part of the gastric fundus, which is the part that will be used for the fundoplication if we need it. And I will cut two little pieces that I will use on the crura. So this is too large for the crura so I’ll cut it in two pieces. I will probably use 4-5cm in length and it should be sufficient to go on the posterior part of the crura. The idea is to reinforce the suture and avoid a cutting effect. I am entering the pledgets and then I will try to get this little coverage of peritoneum, careful with the aorta, which is not that far. Keep an eye out for the vena cava, see it out there. See that my right is almost still, I am tying with my left hand so that I can keep a very short thread. I am trying to get a very good bite in the muscle. You see that the size of the esophagus is almost the size of my repair, I will remove this part so I won’t have any contact between the muscle and the prosthesis. I will probably leave it like this and then moreover, I will do a valve. I am trying to keep this pledget outside of the edge of the muscle. So you see, something like that, a partial valve.
10. Stitches reinforcement 25'02''
Another solution is to place another stitch to reduce the size of the hole within the diaphragm and we are also adding some sutures that will fix the anti-reflux mechanism, the partial posterior valve, on the diaphragm, and together with these different stitches, the size of the hiatus is reduced and hopefully we will avoid the re-herniation. We know also that one of the causes for this massive early postoperative herniation is quite important stress on the diaphragm. This stress is probably due to the recovery from the anesthesia and we suspect that it is the mechanism that leads to this sort of problem in these patients. When we have finished replacing this fundoplication below the diaphragm, we insist with the anesthesiologist on a very safe and unstressed recovery, and sometimes we recommend to instill Lidocaine in order to avoid coughing with the tracheal tube in place when the patient is recovering. In this patient, we observed these different rules and the postoperative period was completely uneventful. Of course, we checked on the first day again with a swallow the position of the stomach and we had a good result. Six months after the surgery, the patient is still doing well, with a valve that is still in a proper position, so the main problem is probably related to the early postoperative recovery period. Every surgeon dealing with this sort of problem should be aware of this possibility. Usually, when we are replacing the stomach in a proper position in this early re-herniation, we recommend to use some drainage of the mediastinal cavity because of the risk of oozing, bleeding or small amounts of fluids in this cavity is high, so it is preferable to leave a drain for 48 hours before the patient is discharged. This is the final picture after the redo and we see that the valve is in the right position.