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Surgical Treatment of Giant
Hiatal Hernia
Paula A. Ugalde
Associate Professor
Thoracic Surgery Department
Laval University
Quebec- Ca
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Purpose: Review current concepts of PEH……
• Overview and Clinical Presentation
• Surgical management
– Laparoscopic technique
• Controversial Issues
• Video presentation
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Categories of Hiatal
Hernia
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Overview and Clinical Presentation
Patulous Cardia Sliding Hiatal
Hernia
Early Incarceration
(Rolling Phase)
End-Stage
Incarceration
Type I Type II & III Type IV
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Should we operate?
Skinner and Belsey (1967)
- nonoperative observation of 21 minimally symptomatic patients
- 26% died of catastrophic complications
Treacy and Jamieson (1987)
- monitored 24 patients
- elective surgery in 13 (54%) because of progressive symptoms
-none needed emergency surgery
Haas (1990)
- 21 patients intrathoracic volvulus (8 asympt)
-10 required emergency surgery
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• Chest X-ray/CT Scan
• Retrocardiac Air Fluid Level
• Barium Contrast Studies
• obstructed intra-thoracic stomach
• “upside down” stomach
Overview and Clinical
Presentation
Radiographic Findings:
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Many patients with giant HH have significant
symptoms. These include:
• reflux
• mechanical complications of an intrathoracic
stomach (chest pain, dysphagia, aspiration,
dyspnea)
• bleeding
• anemia
Overview and Clinical
Presentation
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• Gastric obstruction
• Gastric incarceration
• Gastric strangulation
• Occult anemia/gastric ulceration
• Pulmonary aspiration
Complications of Paraesophageal
Hernia:
Overview and Clinical
Presentation
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Surgical Management
• If a complication occurs, emergency repair is associated
with a 30-50% mortality
• Surgical dogma:
– Should we repair all giant hiatal hernias?
• More recent data suggest the rate of acute presentation
is less than 1% /year and minimally symptomatic giant
hiatal hernias can be observed
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• Open
• Transthoracic
• Transabdominal
• Minimally Invasive
• thoracoscopic
• laparoscopic
• Gastropexy Alone
Which operative approach?
Surgical Management
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Reduced hospital stay
Early return to activities
Equivalent repair success rate to open approaches
Potential Advantages:
Significant learning curve
Frequent difficult dissection
Potential Disadvantages:
Surgical Management: Laparoschopy
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• Experience
• Hernia contents/volvulus make identification of anatomy difficult
• Dissection of large sac bleeding poor visualization
• Fundoplication might be difficult
• Safe dissection of anatomically abnormal hiatus
• Dealing with a shortened esophagus
• Management of large diaphragmatic defect
Surgery is technically challenging….
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• Experienced esophageal surgeons and referral centers • Fundamental operative steps:
– Identification of the plane between the hiatal hernia sac and mediastinal pleura
– Meticulous dissection of the hernia sac – Preservation of peritoneal lining and the integrity of the
crural muscle – Liberal use of esophageal lengthening – Tension-free approximation of intact crura
– consider mesh – Release maneuver
• Anti-reflux procedure • Long follow-up
Surgical Management: Laparoschopy
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Surgical Management: Laparoschopy
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Esophageal Hiatus
• Lighted bougie facilitates esophageal identification
• Need complete circumferential dissection of hiatus to promote closure and esophageal length
• Leave fascia/parietal peritoneum overlying crura
• Beware vagus nerves
• Change visual field often to give perspective
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Key Elements: Sac Dissection
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Reduction of hernial contents
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• Atraumatic graspers
• Take care while reducing hernial contents b/c stomach wall may be ischemic/atrophic and prone to perforation
• Sac dissection
• Experienced assistant providing retraction
Reduction of hernial contents
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Maintaining the Crural Integrity
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What to do if you encounter a short
esophagus?
• Look for it!
• Keep working to gain length !
• Have a plan!
• Open if necessary!
• Laparoscopic Collis in selected cases
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LL Swanstrom et al. Arch Surg 133:869, 1998
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Hiatal defect
Chest cavity
Stomach
Left crus
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Alternatively Mesh can be used to close very large defects
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Esophageal Hiatus
Liver
Esophagus
Left Crus
Right
Crus
Aorta
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Diaphragmatic defect:
• Nonabsorbable suture
• Simple closure
• Pledgets
• Mesh / PTFE
• Mesh over relaxing incision
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Mesh repair
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Liver
Repaired
crura
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Anti-Reflux Maneuver
• Most perform one?
• 50% have a pre-op history of GERD
• 20-30% will reflux postoperatively
• Circumferential dissection of GEJ disrupts natural antireflux mechanisms
• Facilitates intraabdominal anchor
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Completed Repair
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Successful Repair of Giant Paraesophageal
Hiatal Hernia?
• Several Important Steps • Identification of the plane between the hiatal
hernia sac and mediastinal pleura and meticulous dissection of the hernia sac
• Mobilization of the crura, maintaining the peritoneal lining and the integrity of the crural muscle
• Tension-free approximation of intact crura, if either of these conditions cannot be met, consider mesh cruroplasty
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Conclusions • Complex giant hiatal hernias can be managed successfully by
the laparoscopic approach in selected, experienced centers
• Same concepts as open operation should be adhered to
- Reduction of HH, sac excision, hernia repair,
fundoplication
• Operative principles
– Reduce hernial contents
– Excise sac
– Repair diaphragm without tension
• Simlpe sutures pledgets Mesh
– Fundoplication
• Failure to recognize and treat a short esophagus contributes to recurrences, mesh in some cases
• Failure to accomplish complete mediastinal sac dissection and maintain crural integrity
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Conclude: Laparoscopic repair of PEH is ….
• Difficult
• Technically feasible, safe, effective
• With laparoscopy we are also learn how to perform the open procedure better….