Main steps in hiatal hernia repair
As reviewed in chapter 2, the main principles of hiatal hernia repair are:
- Reduction of the hernia contents into the abdominal cavity.
- Dissection and sac excision.
- Correct repositioning of the esophagogastric junction.
- Dissection of the diaphragmatic pillars.
- Crural repair.
Rationale for an antireflux procedure
There are many reasons to perform an antireflux procedure during paraesophageal hernia repair. First, it can help keep the stomach in an intraabdominal position and, second, it prevents the development of reflux symptoms after hernia repair (the failure to perform an antireflux procedure can lead to symptomatic postoperative reflux in 20% – 40% of patients).
The most popular antireflux procedures, which will be discussed in the next slides, are divided into:
- Full or 360º fundoplication (Nissen procedure).
- Partial fundoplications:
- 180º anterior fundoplication (Dor procedure).
- 270º fundoplication (Toupet procedure).
Several randomized clinical trials have concluded that the outcomes of the laparoscopic approach to fundoplication are equivalent to those of the open approach, and are associated with a shorter hospital stay, less postoperative pain, fewer wound-related complications, and an earlier return to normal activities. Thus the laparoscopic approach should be preferred over the open approach.
- The patient is placed in the upright split-leg position, with both arms tucked and secured to the operating table. The surgeon stands between the patient’s legs with the monitor over the patient’s head. The first assistant stands on the patient’s left, the second assistant on the patient’s right, and the scrub-nurse on the patient’s right.
- A five-port technique is usually used.
- 10 mm camera port superior and to the left of the umbilicus.
- 5 mm ports in the right and left flank, epigastrium and right upper quadrant.
- The patient is placed in the reverse Trendelenburg position.
The Nissen fundoplication consists of a 360 degree fundoplication. The main steps of the procedure are listed below:
- Circumferential crural dissection with preservation of the vagus nerves.
- Circumferential dissection of the esophagus at the gastroesophageal junction.
- Adequate mobilization of the esophagus to ensure 2-3 cm of intraabdominal esophagus. If this is not possible, a Collis gastroplasty may be necessary.
- Crural closure with interrupted sutures.
- Gastric fundus mobilization with division of the short gastric vessels.
- Creation of a short (considered as less than 2 cm wide), floppy fundoplication anchored to the esophagus.
Some important tricks are:
- During lesser curve dissection, an aberrant left hepatic artery may be present in the pars flaccida in 13% of patients.
- The use of thermal devices during mediastinal dissection should be limited to avoid undetected injury to the vagus nerves or the esophagus.
- Once the retroesophageal tunnel is made, a Penrose drain passed around the esophagus and secured with clips is useful to retract the esophagus.
- Crural closure should incorporate the crural peritoneum to avoid splitting the crural musculature.
- The shoeshine maneuver consists in sliding the fundoplication back and forth behind the esophagus to confirm good position.
- The most superior stitch of the fundoplication is placed 2.5 cm proximal to the esophagogastric junction with simple non-absorbable sutures that should grab the full-thickness of the fundoplication on each side. One of the stitches should grab a partial-thickness esophageal bite.
- The tightness of the fundoplication is tested by passing a grasper that should easily slide along the esophagus and allow for a lateral retraction of the wrap.
A full description of the technique with tips and tricks was performed live and is available at Laparoscopic Nissen Fundoplication, performed by Dr. François N. Schutte.
This follows the same steps as the Nissen fundoplication except for the creation of the fundoplication. The Dor procedure involves the reconstruction of the angle of His by suturing the gastric fundus to the mid left crus. Subsequent sutures from the greater curvature to the rim of the hiatus roll the fundus up and over the anterior gastroesophageal junction, resulting in a 180º anterior wrap that is secured to the diaphragm.
This follows the same steps as a Nissen fundoplication but each bite of the hiatal closure should include a slip of the posterior wrap. Additionally, sutures are placed from the greater curvature of both sides of the wrap to their corresponding crus. The edges of the wrap are tacked to the esophagus at 2 o’clock and 10 o’clock. As a result, a 270º fundoplication is created.
Controversies regarding fundoplication
Discussion on the best fundoplication procedure is still ongoing in surgical forums. A review of the literature will be the focus of the next chapter of this series on Paraesophageal Hernia Repair.