As to the surgical approach and technique, there are no clear guidelines and several controversies persist. Many surgeons prefer laparotomy, whereas others prefer thoracotomy. Proponents of thoracotomy claim that the wide exposure afforded by this approach permits maximal mobilization of the esophagus in the event that a short esophagus is revealed at the time of surgery, or if the patient is found at surgery to have a massive nonreducible Type III or IV hernia. Since the introduction of minimally invasive surgery, the trend has been to approach these hernias laparoscopically. However, given the often complex presentation of these cases, conversion to open surgery may become necessary and the surgeon should be familiar with all surgical approaches before undertaking this repair to tailor the intervention to the patient's individual situation.
It is now well accepted that a complete excision of the hernia sac is mandatory to avoid recurrence of the hernia.9,10 It is probably easier to excise the sac through a thoracotomy, but with increasing experience, it appears feasible to obtain complete excision through a laparoscopic approach (Fig. 46-3). Whatever the route of access, it is of paramount importance to resect the sac without damaging the vagus nerves. With the laparoscopic approach, the sac should be excised before mobilizing the esophagus and by staying away from the esophagus (Fig. 46-4A,B). This can be done by everting the sac at the beginning of the intervention and incising the sac at the border of the hiatus but avoiding damage to the crural muscle. After entering the mediastinum, the sac is further dissected and pulled down allowing both vagi to be identified. It is also important to identify the pleura to avoid inadvertent opening of the pleural sac, which may result in hemodynamic instability due to tension pneumothorax. It is also important to keep the peritoneal covering of the crura intact, or it will be difficult to obtain successful primary closure of the hiatus.
Surgeon and port placement.
Once the hernia is reduced (Fig. 46-5), the next step is to mobilize the esophagus in the posterior mediastinum. This step is essential to achieving adequate esophageal intra-abdominal length. In particular, full mobilization up to the level of the carina is mandatory in patients who present with a suspicion of short esophagus. In some of these patients, the presumed short esophagus is simply the result of loss of elastic recoil and adequate intra-abdominal length is easily obtained. In patients with a true shortening of the esophagus, adequate length may be difficult to achieve. For these cases, it can be helpful to completely mobilize the fat pad off the stomach and the distal esophagus, again taking great care not to damage the vagus nerves (Fig. 46-6). This maneuver allows one to identify more precisely the true anatomic junction by visualizing the longitudinal esophageal fibers. It also allows one to gain some additional length, which is required for a tension-free 2-cm intra-abdominal length.
An intraperitoneal stomach is established after the hernia sac has been reduced.
The esophageal fat pad is identified and mobilized at the GEJ.
Although this intra-abdominal segment contributes to the antireflux barrier, it also provides the necessary length to perform an antireflux procedure under optimal conditions.11 Indeed, given the fact that reducing a large hernia sac requires extensive esophageal dissection and causes disruption of, what is for most patients, an already deficient antireflux mechanism, significant postoperative reflux will be the most likely consequence.
If, despite all these maneuvers, the necessary 2 cm cannot be obtained, a gastroplasty is unavoidable. There are several ways to perform a gastroplasty, but today most surgeons prefer the wedge Collis gastroplasty (Fig. 46-7),12 usually in combination with a 360-degree short floppy Nissen fundoplication (see Chapter 39). If the patient has a clear motility disorder, a partial fundoplication, for example, Toupet, is usually preferred (see Chapter 40). When an open transthoracic approach is used, and if, after full mobilization of the esophagus up to the level of the aortic arch, an insufficient length is obtained, a Collis Belsey gastroplasty is performed as described by Pearson et al.7 and illustrated in Chapter 38.
Complete mobilization of the fat pad permits visualization of GEJ and assessment of esophageal length.
The use of gastropexy is controversial. Nissen13 and Boerema and Germs14 were the first to use gastropexy to anchor the stomach against the abdominal wall in an effort to decrease the incidence of recurrence after repair of a paraesophageal hernia. Ponsky et al. in 200315 showed favorable results of gastropexy after laparoscopic repair of paraesophageal hernia with no recurrence at 2 years follow-up in a series of 28 patients. However, Larusson16 found gastropexy to be one of the variables associated with an increase in postoperative morbidity.
Some surgeons prefer gastropexy over antireflux procedures in frail and elderly patients because of the potential undesirable side effects of the latter that eventually may jeopardize the postoperative course. If symptomatic reflux occurs, it is hoped that this can be controlled with medical therapy (proton pump inhibitors [PPIs]).
The final but equally critical step of this intervention is the closure of the hiatus (Fig. 46-8A,B). The risk for recurrent herniation is greater with paraesophageal hernia compared with Type I sliding hernia, because of the widening of the hiatus and weakening of the muscles, especially the left crus, caused by the large herniated stomach. This has stimulated some surgeons to use prosthetic materials to minimize the risk of recurrence.17 Prosthetic material can be used as an “onlay mesh” draped over the closed pillars and around the esophagus or actually as a “curtain” incorporated in the hiatus itself. Given the presumed higher risk for erosion into the esophagus or stricture formation, most prefer to use Gore-Tex or biomaterials such as Surgisis.
Tension-free hiatal closure.
Zaninotto et al.18 found a 42% recurrence rate after repair without reinforcement of the crura versus 9% with mesh reinforcement using Gore-Tex. A randomized controlled trial using the biologic prosthesis, Surgisis, showed initial superiority over closure without mesh with 9% versus 24% recurrence rates, respectively.19 This advantage appears to diminish over the long term.
For the majority of cases, if the surgeon uses meticulous technique and avoids stripping away the overlying peritoneum, the crura can be sufficiently mobilized to permit a tension-free closure.
Nason et al.10 have found it helpful to create a pneumothorax on the left side by introducing a pigtail catheter. This results in a laxity of the left pillar as the diaphragm becomes floppy. Usually three to four stitches will suffice, and to avoid too much anterior displacement, additional sutures in front of the esophagus may be necessary to obtain sufficient narrowing of the hiatus.