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INDICATIONS

Laparoscopic repair of giant hiatal hernias, also known as paraesophageal hernias, is indicated for individuals with a symptomatic type II or III paraesophageal hiatal hernia. Symptoms are variable, including gastroesophageal reflux disease (GERD), dysphagia, chest or abdominal pain, or anemia. The patient must also be a candidate for a transabdominal approach to the hiatus, which excludes those with uncorrectable coagulopathy, contraindications to laparotomy, or a hostile abdomen, as well as patients who have had several prior failed laparoscopic operations, in which case an open procedure should be strongly considered.

PREOPERATIVE PREPARATION

Before undergoing laparoscopic paraesophageal hernia repair, anatomic and physiologic esophageal evaluation should be performed. This entails the performance of esophagogastroduodenoscopy (EGD), barium swallow, and esophageal manometry. A 24-hour pH test is not needed, as all patients will receive a fundoplication, either total or partial, depending on the adequacy of motility. The remainder of preoperative preparation and intraoperative anesthetic management is similar to that for Nissen fundoplication (see Chapter 18).

POSITION

Laparoscopic esophageal procedures are typically performed with the surgeon standing between the patient’s abducted legs and with the patient in a steep reverse Trendelenburg position. The assistant typically stands on the patient’s left side (Figure 1). Initiation of the pneumoperitoneum, placement of trocars, and liver retraction are all similar to that for laparoscopic Nissen fundoplication (see Chapter 18) (Figure 2).

DETAILS OF THE PROCEDURE

After exposing the area of the esophageal hiatus by liver elevation, the surgeon and assistant reduce the intrathoracic stomach by hand-over-hand manipulation using atraumatic graspers. The gastrohepatic omentum is divided with the ultrasonic shears, including division of the hepatic branch of the vagus nerve for optimal exposure of the right crus of the diaphragm. The most important aspect of the operation is to gain entry into the proper plane between the peritoneum and endothoracic fascia (Figure 3).

DETAILS OF THE PROCEDURE

Typically a large paraesophageal hernia contains two distinct sac elements. The anterior hernia sac is an extension of the abdominal peritoneum (greater sac of the abdomen) while the posterior hernia sac is an extension of the lesser sac (Figure 4 inset). To reduce the anterior sac, the assistant grasps the stomach along the high lesser curve and retracts it to the patient’s left (Figure 4). This maneuver often reveals that large amounts of fat and vessels of the lesser curvature of the stomach, including the left gastric artery, have been drawn into the mediastinum. In this case dissection of ...

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