Rolling (paraesophageal) hiatal hernia treatment in an 80-year-old male patient

This is a 'live' surgical video demonstrating a hiatal hernia repair by Dr. Bernard Dallemagne. Every step of the operation is discussed with the expert panel and workshop participants. This video is recommended to upper GI surgeons.

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Rolling   (paraesophageal)   hiatal   hernia   treatment   in   an   80-year-old   male   patient

Authors
B Dallemagne, J Marescaux
Abstract
This is a 'live' surgical video demonstrating a hiatal hernia repair by Dr. Bernard Dallemagne. Every step of the operation is discussed with the expert panel and workshop participants. This video is recommended to upper GI surgeons.
Keywords
hiatal hernia repair
Media type
Duration
20'00''
Publication
2007-10
Popular
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Oct 2007;7(10).
URL: http://www.websurg.com/doi-vd01en2167.htm

Rolling   (paraesophageal)   hiatal   hernia   treatment   in   an   80-year-old   male   patient

1. Trocar placement 00'31''
Here is the anatomy. I’m just checking my entry point into the cavity. This is a very strange anatomy, here’s the chest, the liver; the prosthesis is there, so you can look at the outcome of the preperitoneal repair with this mesh. There are still some adhesions there probably on the repair. We will try to put a first port. It’s a little bit difficult because here you see that it’s the chest, so we’re working high in the chest. I will use a 1st port probably somewhere here. So we’re almost at the level of the left iliac spine. Be very careful when you introduce the trocars always under visual control. The patient is so thin. The trocar heads towards the operative field. Then my right hand is on the left side of the patient, between the two first ones, but the costal margin is very low. So it’s one 12mm for the optic and all 5mm. Of course, we could do it with all 5mm ports and a 5mm scope, but it’s more difficult to introduce the needle, so the liver retractor is coming from the right side of the patient. Here we have a nice view. As mentioned earlier, the pylorus and the antrum of the stomach are just on the right crus. We should have some stomach there, probably part of the fundus, and the rest of the stomach is really into the chest. You can imagine that it may create problems at times. You see that there is a twist there with part of the fundus, body of the stomach. The initial idea is not to try to reduce absolutely this stomach and maintain it into the abdominal cavity and dissect within the sac. We have to work outside of the sac. That’s the key point for this repair. We will start outside of the sac. Here it’s easy because the landmarks are evident. We will work on the outside of the hiatal orifice.
3. Dissection of hernia sac 05'00''
This is the muscle so I know that I’m coming to the right plane. And normally just with blunt dissection we can find the plane between the sac and the normal mediastinal structures. We are changing the position of the lateral grasper and exert traction on the sac. So always outside of the sac and I try to preserve the sac. This plane is an easy one. And then again, we find the muscle on the left side. With blunt dissection, we retract the tissues because we don’t know where the pleura is. Now the key thing is to go down on the left crus. It’s important to find the right plane because otherwise it starts to bleed a little bit and becomes very difficult to deal with that. So these are the normal attachments of the phrenogastric ligament that we will divide. I’m used to working from the right crus and the upper part of the hiatus. Now we will reduce the sac. I’m trying to preserve the pleura, which should be somewhere here. You cannot always identify exactly the plane, so again with blunt dissection we try to keep only the sac. I know that the pleura is not there. And when you are in the right plane, the cleavage is quite easy. I didn’t look at the position of the esophagus because I know that as soon as I will reduce the sac, I will find the mediastinal structures. Somewhere we should find the esophagus. It’s the anterior vagus trunk which runs on the left side of the patient. Probably the pleura is here. There is still part of the sac there. There is still some pleura there. You have to preserve the pleura. It’s not a big deal if you cause some injury. But usually in such fragile patients you try to avoid that. It’s like a sac for an inguinal hernia. You just reduce it. Now I know where is the esophagus. We can still see a bit of the pleura there. This is the sac. I think everything can be reduced into the abdomen. If I want to go behind the esophagus, I have to open this space in the same way as we’re doing for antireflux surgery. Now we’ll try to find our way behind the esophagus and try to identify the vagus trunks. We’ve seen the anterior one. I’m trying to find the left crus, find my plane, and reduce the sac. So if I’m close to the crus, there’s no risk. And I’m trying to follow the crus. This is the left crus there. These are the posterior attachments. The problem is that we have to reduce the junction within the abdomen.
4. Dissection of esophagus 14'45''
We have to mobilize the esophagus quite a lot to get it back into the abdominal cavity. I don’t know exactly where is the plane, so I’m looking above and hopefully I can find my plane there. The idea is to get the general orientation of the esophagus, so we can recognize the plane where we have to go. As mentioned before, we try as much as possible to get some information about the motility of the esophagus because if we’re doing an antireflux repair, we can induce dysphagia. If we know that the esophagus is good, we’re free to do other things. Probably the vagus trunk is there. We try to place it in a normal position. There’s a complete distortion of the anatomy, that’s why I’m using a lot of blunt dissection in order to recreate the normal plane and so I can identify the structures before cutting or coagulation. You can imagine that if you work directly within the sac you will cut the vagus trunk and lots of other important stuff. This is the aorta, a major structure into the mediastinum. This is done for the left side. We will move a bit on the right again. You can see that we have replaced the vagus trunk in the proper position. This is the vagus trunk there so I try to keep it alongside the esophagus. We’re on the vertebral body. I’ve the feeling that there is some distortion of the esophagus. Maybe it’s some adhesions with the pleura. Sometimes you see when they have a small diverticulum, you can see some adhesions. The vagus trunk is there, well fixed. You see that I have the junction in my left hand and I can reduce it progressively. We are now above the sac around the esophagus so we’ll use the ribbon tape. You need to take your time to mobilize further. I don’t like the hook in this kind of dissection because you need some blunt device. Ultrasonic devices are quite good because they are blunt dissectors. Here you see a lymph node. We won’t do an esophagectomy today. Next step is the sac excision. I want to see the junction clearly.