''Upside down'' stomach: laparoscopic repair

This video demonstrates the laparoscopic technique for repair of a large hiatal hernia associated with a supradiaphragmatic stomach.

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''Upside down'' stomach: laparoscopic repair

Authors

B Dallemagne, C Solano, J Marescaux

Abstract

This video demonstrates the laparoscopic technique for repair of a large hiatal hernia associated with a supradiaphragmatic stomach.

Keywords

laparoscopy, repair, upside down stomach

Media type

Surgical video

Duration

10'50''

Publication

2008-04

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E-publication

WeBSurg.com, Apr 2008;8(04).
URL: http://www.websurg.com/doi-vd01en2218.htm

''Upside down'' stomach: laparoscopic repair

1. Case history 00'16''

This is the case of a 68-year-old female patient with a long history of gastroesophageal reflux disease. She also has occasional dysphagia. An upper gastrointestinal endoscopy in 2004 showed a hiatal hernia with esophagitis. A second test performed 3 years later showed reflux associated with the hiatal hernia. A preoperative barium swallow demonstrates that the entire stomach lies in a supra-diaphragmatic position.

2. Patient and trocar positioning 00'44''

This is usually called an “upside down stomach”. For the operation, the patient is placed in a steep reverse Trendelenburg position, with the legs apart. A 10mm trocar is used on the midline two thirds from the xiphoid process to the umbilicus for a 0 degree laparoscope. Two retracting 5mm trocars are located in the right and left anterior axillary line just below the costal margins. Two 5mm operating trocars are then placed in the epigastrium, one just below the right costal margin, and the other on the mid-clavicular line in the left upper quadrant.

3. Operation commences 01'48''

The contents of the hiatal hernia are maintained in the abdomen with the aid of a grasper placed on the anterior fat pad in front of the gastroesophageal junction.

4. Dissection and reduction of hiatal hernial sac 02'00''

Then the pars condensa is opened with the aid of an ultrasonic device. By doing this, we identify the right diaphragmatic crus, and then dissection of the hernial sac can be started. When approaching giant hiatal hernias, one frequent error is to go within the sac looking for the esophagus. However, the objective is in fact to begin our surgery using an extra-sac approach. In other words, the hernial sac is dissected from the rest of the structures and then brought intra-abdominally. Once the sac is reduced, the esophagus is better identified and can then be dissected from its lateral attachments. Dissection of the esophagus into the mediastinum lengthens the abdominal portion of the esophagus. The dissection can be extended up to the pulmonary veins, preserving the vagus nerves at all times. The hernial sac is now cut from the esophagus to ensure a fine dissection of the gastroesophageal junction and consequently to ensure an adequate hiatal repair. At least, 2cm length of the esophagus should be placed intra-abdominally without tension. Next, a tape held with a grasper is placed through the enlarged retro-esophageal window and placed around the esophagus. By this means, we avoid any traumatic injury to the stomach by direct application of the graspers.

5. Antireflux wrap 06'28''

We now continue with the mobilization of the gastric fundus and this will be used to create the anti-reflux valve. We start by dividing 2 or 3 gastric vessels as well as the gastrophrenic ligament. Now the cruroplasty is performed using reinforced sutures with pledgets. This would restore one of the elements of the anti-reflux barrier and stabilizes the anti-reflux wrap within the abdominal cavity.

6. Crural repair 07'45''

Hiatal closure can be performed by simple suture closure, prosthetic reinforcement, and finally Teflon pledgets. In our institution, however, we tend to avoid using prosthetic reinforcement due to its association with stenosis and erosion. Teflon pledgets, however, are easy to apply and inexpensive. They are placed anteriorly to the crura and sutured in placed with non-absorbable sutures. During the repair and fundoplication, it is recommended to place a 55 French bougie into the esophagus to accurately calibrate the esophagus and avoid any strangulation. In this case, a large hiatal defect is present. Therefore, two anterior sutures are placed in front of the esophagus. Then, the esophagus is pulled up using the loop, and this allows passage of the stomach’s posterior wall. The anterior fundic wall therefore moves towards the posterior aspect of the esophagus. The Nissen fundoplication should be 2cm in length and height. Finally, the resected hernial sac is placed into a retrieval bag and removed to the exterior.The postoperative barium swallow shows an infra-diaphragmatic positioned stomach, without any sign of a hernial defect.