of Paraesophageal Hernia

Fig. 17.1

Hiatal hernia classification

Type I hernias are the most common and account for up to 95% of the total prevalence. Type II, III, and IV hernias are together termed paraesophageal hernias (PEH) and combined account for the remaining 5% of hiatal hernias.

Clinical Findings

As mentioned above, many patients remain asymptomatic, and their hernias are diagnosed accidentally. Large PEH, on the other hand, may cause a wide variety of symptoms such as epigastric discomfort, chest pain, postprandial bloating, dysphagia, or respiratory problems (asthma, cough, or dyspnea caused by chronic aspiration). In addition, patients may experience symptoms due to gastroesophageal reflux (heartburn or regurgitation). Anemia secondary to gastric erosions can also be present.

Rarely, patients may present with acute severe symptoms and potentially lethal complications such as volvulus, strangulation, incarceration, and perforation (Fig. 17.2).

../images/473262_1_En_17_Chapter/473262_1_En_17_Fig2_HTML.jpg — Fig. 17.2

Gastric volvulus

Diagnosis

Several tests are needed preoperatively to determine the anatomy and physiology of the esophagus and stomach.

Barium Swallow

This study is critical in order to delineate the anatomy and the type of hiatal hernia. The ability to distinguish between different hernia types helps in determining the complexity of the operation (Fig. 17.3).

../images/473262_1_En_17_Chapter/473262_1_En_17_Fig3_HTML.png — Fig. 17.3

Barium swallow showing a large paraesophageal hernia

Upper Endoscopy

An upper endoscopy is also useful to determine if gastric or esophageal inflammation is present and to rule out cancer. Cameron ulcers are ulcerations of the mucosal folds lining the stomach due to extrinsic compression of the diaphragm on the distal neck of a hiatal hernia. Though typically asymptomatic, they may present as acute and severe upper gastrointestinal bleeding.

Abdominal and Chest CT Scan

This test is particularly important if the presence of a Type IV hernia is suspected (Fig. 17.4).

../images/473262_1_En_17_Chapter/473262_1_En_17_Fig4_HTML.png — Fig. 17.4

Computed tomography showing a Type IV paraesophageal hernia; (a) sagittal plane; (b) coronal plane; (c) axial plane

Esophageal Manometry

Abnormal esophageal motility is common in these patients. A partial fundoplication is preferred if there is severely impaired peristalsis. If the manometry is technically unfeasible or the patient cannot tolerate the catheter, a partial fundoplication should also be performed.

Although patients with PEH usually have pathologic reflux, performing a pH monitoring study does not add relevant information preoperatively. The operation will alter the physiology of the EGJ, and a fundoplication to prevent reflux will be performed regardless of the results of the study.

Cardiac- and pulmonary-related tests are performed on a case-by-case basis, particularly because these patients are often elderly .

Surgical Repair of PEH

Historically, surgical repair has been advocated in all patients with PEH, even when asymptomatic, due to the considerable mortality associated with acute hernia incarceration and strangulation. Currently, nonsurgical management is considered a better alternative in asymptomatic or minimally symptomatic patients because the risk of strangulation is lower than the risk of morbidity associated with the operation. Therefore, surgical repair is indicated mainly for symptomatic PEH [2].

Traditionally, PEH repair required either a laparotomy or thoracotomy, and these approaches were associated with high morbidity. Since its introduction in 1992, the laparoscopic approach has been increasingly embraced due to its improved postoperative outcomes [3, 4]. Nowadays, the vast majority of patients with PEH are managed with a laparoscopic approach.

Laparoscopic PEH Repair

Positioning of the Patient

After induction of general endotracheal anesthesia, an orogastric tube is inserted to keep the stomach decompressed. The patient is positioned supine in low lithotomy position with the lower extremities extended on stirrups, with knees flexed 20–30°. To avoid sliding due to the steep reverse Trendelenburg position used during the entire procedure, a bean bag is inflated to create a “saddle” under the perineum. Pneumatic compression stockings and subcutaneous heparin are always used as prophylaxis against deep vein thrombosis (particularly important as the increased abdominal pressure secondary to the pneumoperitoneum and the steep Trendelenburg position decrease venous return). The surgeon stands between the patient’s legs and the first and second assistants on the left and right side of the operating table, respectively.

Trocar Placement

Five 10-mm ports are used for the procedure: one for the camera, two for the operating surgeon, one for the assistant, and one for the liver retractor. The first port is usually placed in the midline about 14 cm below the xiphoid process; it can be also placed slightly to the left of the midline to be in line with the esophagus. This port is used for insertion of the scope. The second port is placed in the left midclavicular line at the same level of port 1, and it is used for the insertion of a Babcock clamp for traction, a grasper to hold the Penrose drain while surrounding the esophagus, or for devices used to divide the short gastric vessels. The third port is placed in the right midclavicular line at the same level of the other two ports, and it is used for the liver retractor. The fourth and fifth ports are placed under the right and left costal margins so that their axes and the camera form an angle of about 120°. These ports are used for the insertion of dissecting and suturing instruments (Fig. 17.5).