Type 1: Sliding hiatal hernia in which the gastroesophageal junction moves cephalad, predisposing to gastroesophageal reflux.

Type 2: Rare hernias in which the gastroesophageal junction remains in its normal anatomic position, and the fundus herniates alongside it into the chest.

Type 3: Classic paraesophageal hernia, in which there are a combination of a type 1 and 2 hernias. Both the gastroesophageal junction and the fundus herniate into the chest. These hernias can be associated with organoaxial rotation predisposing to incarceration.

Type 4: Involves another intraabdominal organ within the hernia sac.

This is a cross-sectional image of the hernia sac demonstrating both an anterior and posterior component. The hernia sac is bisected by the stomach and its gastrohepatic and gastrosplenic ligaments. Both the anterior and posterior sac must be reduced from the mediastinum to complete an adequate paraesophageal hernia repair.

Appropriate cardiac and pulmonary clearance as indicated.

Video barium swallow: Provides anatomic assessment and classification of type of hiatal hernia, paraesophageal component, and esophageal length. The video swallow can also assess esophageal function.

Upper endoscopy: Rules out intrinsic esophageal lesions and allows assessment of esophageal length.

Esophageal motility: This is not routinely ordered as it can be difficult to accurately place a catheter with anatomic distortion.

24-hour pH study: This is not routinely ordered.

Port A: Initial access is gained with an open cut-down technique approximately one third of the distance from the umbilicus to the xiphoid process. It is important that this port is placed no more than 14 cm from the xiphoid process or the camera will not be able to reach high enough to perform an adequate mediastinal dissection.

Port B: 5-mm liver retractor. This port should be placed fairly cephalad to avoid interfering with the surgeon’s left operative port.

Port C: With the liver retractor in place and the left lateral segment of the liver elevated, the next 5-mm port is placed. It is preferable to place this to the patient’s left of the falciform ligament to avoid interference during instrument exchanges. It should be placed just inferior to the left lateral segment of the liver.

Port D: 5-mm first assistant port. This should be placed as far lateral as possible, just inferior to the costal margin.

Port E: 10-mm surgeon’s right-hand working port. This port is placed at least a hand’s breadth away from port C to provide adequate separation, to allow suturing. In patients with a narrow costal margin this should be placed closer to port D to avoid crowding of the surgeon’s two working instruments.

A gentle manual reduction of the hernia contents is initially attempted. The main purpose of this maneuver is to allow some pneumoperitoneum to enter the hernia sac to make dissection easier. No attempt should be made to dissect adhesions within the hernia sac, as the true dissection plane is outside of the hernia sac.

The first assistant grasps the stomach and retracts to the patient’s left, and the surgeon divides the gastrohepatic ligament. This dissection should be carried cephalad until the right crus is identified. Care should be taken to avoid injuring an accessory left hepatic artery (see Pearls and Pitfalls).

This is one of the most critical steps in the procedure. It is important to identify the proper dissection plane to avoid excessive bleeding and damage to major mediastinal structures. It is preferable to begin this dissection at approximately the 11 o’clock position. Typically this is the insertion point of the gastrohepatic ligament into the right crus, and it tends to be the thickest part of the phrenoesophageal ligament. Additionally it is important to begin this plane approximately 3 to 4 mm on the abdominal side of the crus. If the dissection is started further on the abdominal side, the peritoneal covering of the crus is often disrupted, making eventual suture repair very difficult during later steps in the procedure. If the dissection is begun too far in the mediastinum, the hernia sac retracts into the mediastinum and can be difficult to control.

The first assistant grasps the peritoneal edge and the surgeon uses the harmonic to divide the peritoneal coverage of the crus. This plane is all the way down to the muscular fibers of the crus.