Incomplete hiatal dissection
Improperly tied knots
Poor tissue bites
Tightness of fundoplication
Tightness of crural closure
Acid-suppression medication unresponsiveness
Post-operative diaphragmatic stressors
16.2.1 Radial and Axial Tension
There are two major forces acting on the repair of the hiatal hernia that lead to disruption of the repair and ultimate failure: radial tension and axial tension (Fig. 16.1). Radial tension at the hiatus acts upon the diaphragm in a plane perpendicular to the esophagus. This tension results in the movement of crural fibers away from the midline and a widening of the diaphragmatic hiatus. It is opposed by the phrenoesophageal ligament which helps keep the hiatus in place around the esophagus. The dynamic nature of the diaphragm and its constant motion over time causes stretching and even break down of a sutured crural repair with resultant failure and recurrence of the hernia. When the radial forces overcome the forces keeping the hiatus together, the hiatus loosens and allows herniation to occur. When repairing hiatal hernias, increased radial tension is manifested as difficulty re-approximating the left and right crural pillars.
Diagram of forces acting upon the esophagus and GEJ. Axial tension acts parallel to the esophagus and causes cephalad migration. Radial tension acts perpendicular to the esophagus but parallel to the diaphragm and results in widening of the crura
Axial tension is related to the cephalad forces acting on the esophagus both intrinsically and extrinsically and is manifest as the tendency for the gastroesophageal junction (GEJ) to migrate upward into the mediastinum. There is a natural physiologic movement of the GEJ of up to 2.5 cm in non-hernia patients, with the phrenoesophageal membrane acting as an elastic recoil mechanism to return the GEJ to its proper anatomic configuration . When the phrenoesophageal ligament becomes attenuated, the amount of recoil decreases and results in herniation . Additional forces include negative intra-thoracic pressure, positive intra-abdominal pressure, contractile forces of the longitudinal esophageal musculature, and increased intra-gastric pressure. In addition, chronic displacement of the GE junction into the chest combined with fibrosis from recurrent esophagitis can make re-establishment of adequate intra-abdominal esophagus difficult (short esophagus), with resultant axial tension on the repair. After primary repair of a paraesophageal hernia, this axial tension acting on the esophagus continues unopposed and can result in disruption of the hiatal closure or any fixation sutures resulting in intra-thoracic migration of the GEJ and fundoplication.
16.2.2 Technical Issues
There are several technical factors at the time of the index operation over which the surgeon has control and which can result in reduced likelihood of recurrence. A full mobilization of the distal esophagus up to or above the inferior pulmonary veins will improve intra-abdominal length and decrease axial tension on the short esophagus. Intra-operative endoscopy with endoscopic confirmation of the squamo-columnar junction will aid in correctly placing the wrap at and above the GE junction rather than too low.
The actual shaping of the fundoplication by utilizing the correct portion of the fundus and bringing it around the esophagus with the proper configuration is critical. If the gastric body rather than the fundus is used to construct the wrap, a type III failure may occur (Fig. 16.2). In order to avoid an overly tight wrap, the fundoplication is most often constructed over a bougie. Data suggests a decrease in post-operative dysphagia with the use of a bougie. There is however a real possibility of dilator perforation during insertion, which is estimated at 1% [10, 11]. In addition, standardization of crural closure has been elusive, and an overly tight cruroplasty may lead to postoperative dysphagia and need for dilation or revision, whereas overly loose closure can be a factor in recurrent herniation.
Classification of fundoplication failure . Type Ia—The entire wrap along with the GEJ migrates cephalad. Type Ib—The wrap remains below the diaphragm but the stomach and the GEJ slip cephalad. Type II—True paraesophageal hernia. Type III—Defective initial construction of the wrap using the gastric body rather than the fundus (modified with permission from ref. )
16.2.3 Patient Factors
There are several factors relating to the patients that can affect the rate of recurrence. Paraesophageal hernias occur mainly in the aging population, which is likely related to attenuation of the phrenoesophageal membrane (and perhaps other connective tissue involving the repair) and subsequent recurrence . Factors that put patients at a higher risk of failure are pre-operative (body mass index) BMI >35, unresponsiveness to acid-reducing medications, atypical symptoms, and psychiatric illness . While there is no absolute BMI cutoff beyond which a repair should not be performed, dietary counseling and referral to a bariatric surgeon should be considered for any patients with BMI >35. Post-operatively, tight nausea control should be implemented in order to avoid retching, which can increase intra-abdominal pressure and is a primary factor associated with recurrence. In addition, patients should be counseled to avoid any inordinate heavy lifting, straining or strenuous exercise which could lead to increased intra-abdominal pressure and resultant recurrence.
16.2.4 Classification of Failures
Anatomic failure can be classified based on the type of failure and it is helpful to identify the type of failure as an indicator of the underlying cause (Fig. 16.2). Increased radial and axial tension can lead to a Type IA failure and is seen when the entire wrap along with the gastroesophageal junction migrates cephalad resulting in an intra-thoracic fundoplication. This is the most common type of failure. A variation on this problem is the so-called slipped Nissen , or Type IB failure in which the wrap remains below the diaphragm but the stomach and the gastroesophageal junction slip upward through the wrap resulting in the GEJ residing within the mediastinum. This failure may occur due to misjudging the location of the true GEJ with the wrap placed low around the cardia instead of the fundus, from increased axial tension due to unrecognized short esophagus, or as a result of chronic stress on the GEJ from intra-gastric pressure. When in doubt, poor placement can be avoided by intraoperative endoscopy and identification of the true junction. Type II failure is analogous to the true paraesophageal hernia. Breakdown of the crural repair sutures with an intact wrap and normally located GEJ can result in intra-thoracic stomach with dysphagia, pain, or potential gastric volvulus despite an appropriately placed wrap. Finally, a defective initial construction of the wrap results in a Type III failure as described above, caused by utilizing the mid-body of the stomach to fashion the wrap rather than the fundus.
16.3 Identifying Recurrence After Hiatal Hernia Repair
Identifying and defining symptoms is one of the most important steps in treating recurrent hernias. Many patients experience new symptoms after an otherwise satisfactory primary hernia repair, such as gas-bloat, hyper-flatulence, or mild dysphagia even in the absence of documented anatomical defects or technical errors. Without investigations it may be difficult to determine which symptoms are due to the physiologic effects of the wrap versus the effects of a recurrence. It is imperative then to obtain a good symptomatic history detailing exactly when the symptoms started, progression, and temporal relation to oral intake. Symptomatic management is the first step in the early postoperative period unless there is strong reason to suspect disorder of the repair. For persistent, progressive, or atypical symptoms, objective studies will be needed to determine the presence and correlation of anatomic defects with symptoms.
The most common post-operative symptoms related to recurrence are heartburn, regurgitation, dysphagia, and pain . Any of these may be the result of the repair itself. For example, the sensation of heartburn may be caused by esophageal distension or spasm secondary to the effect of the wrap rather than failure of the repair. However, if any of these symptoms persist beyond the first 3 months, a focused workup should be implemented in order to identify any possible recurrence and assist therapeutic decision-making.
It is reasonable to start with two-phase esophagography. This test will help elucidate esophageal and gastric anatomy including an obstructing repair, anatomic recurrence and its classification, intra-thoracic wrap migration, and strictures or other anatomic abnormalities and is the most sensitive test for recurrent herniation (Fig. 16.3) . It can also provide useful information on the basic function of the gastroesophageal junction and valve, visualizing both transit and reflux, though it is less reliable with regard to recurrent reflux. The pylorus can be examined as well in order better identify vagal injury and resultant hypertonicity of the sphincter mechanism. Anatomic recurrence is commonly defined as 2 or more cm of stomach and/or GEJ above the diaphragmatic crura although several variations of the diagnostic criteria exist .
Images from video contrast esophagograms demonstrating fundoplication failure. Type Ia failure is shown on the left, with both the intact wrap and GEJ herniated above the level of the diaphragm. A type Ib failure is seen in the right image with only the GEJ herniating above the level of the diaphragm while the majority of the fundus remains intra-abdominal
Endoscopy is important in the workup in order to visualize any intra-luminal abnormalities. Erosions, esophagitis, or gastritis can be identified and help reinforce the diagnoses of reflux and recurrence. A recurrent hiatal hernia can be seen and the configuration of the gastroesophageal flap valve based on the Hill system can be graded (Fig. 16.4). The presence of a stricture or narrowing may prompt additional manometric evaluation. Rarely, erosion of suture or mesh into the lumen will be detected.
Endoscopic view of Type II or true paraesophageal hernia failure. Note the GEJ is below the diaphragm but the fundus has herniated cephalad creating a characteristic endoscopic view
Manometry is not an essential part of the evaluation of recurrent PEH, but may prove useful in certain circumstances. If pre-operative manometry is available and the patient denies any new dysphagia, then repeat manometric evaluation is unlikely to add any additional usefulness. However, if the patient has new-onset dysphagia or there is uncertainty surrounding the patient’s esophageal motility, then manometry should be performed to rule out any esophageal motility disorders of the esophageal body or the reconstructed GEJ, to help determine optimal reconstruction.
Objective evaluation of reflux in the form of 24-h pH monitoring is vital to identify the presence of acid reflux, especially if anatomic recurrence is subtle or absent and the etiology of symptoms is unclear. In the case of large recurrent anatomic defects clearly attributable to the patient’s symptoms, pH monitoring is less helpful as re-operation is likely regardless of the pH study outcome. Any patients with symptoms of reflux and a positive DeMeester score in the setting of anatomic recurrence should be considered for revisional surgery.
If there is concern for vagus nerve injury or impaired gastric motility, a gastric emptying study is helpful in determining gastric function. The incidence of gastroparesis requiring a gastric emptying procedure can be as high as 12% after re-operation and increases with each subsequent recurrence . A patient who gives a history of nausea or extended bloating after meals should make the surgeon suspicious for gastric emptying issues. If a gastric emptying test shows delayed gastric emptying, careful consideration must be given to the management of abnormal gastric emptying in the setting of previous hernia repair. If on endoscopy the pylorus is dysfunctional, a trial of endoscopic botulinum toxin may improve emptying and signal a good chance of success for pylorplasty or pyloromyotomy at the time of reoperation . If the sphincter mechanism is functional without increased tone or obstruction, however, then pro-motility agents may be attempted.
16.3.1 When to Operate
The indications for re-operation are similar to those for primary operation: symptoms from herniation such as obstruction/risk of incarceration, dysphagia, anemia, and dyspnea; or symptoms of inadequately controlled reflux. The operative risks and the predictability of success are a bit more problematic and there should be a higher threshold for recommending re-operation, particularly in the elderly. As with primary surgery, it is vital to determine the goals of the operation relative to the patient’s symptoms and objective findings and to weigh the risks against the realistic expectation of benefit. In some cases continued medical management may be the better alternative until the situation progresses.
16.4 Surgical Strategies
Although once the mainstay of re-operative hiatal hernia repair, the open approach has been largely supplanted by laparoscopic paraesophageal hernia repair over the last 20 years. Compared to the open trans-abdominal and trans-thoracic approaches, laparoscopy has been shown to decrease hospital length of stay, postoperative pain, and respiratory complications while offering similar outcomes [18, 19]. In experienced hands, the laparoscopic approach is safe even in the setting of previous laparoscopy or even laparotomy with low conversion rates of around 7% [20, 21]. It has been shown that results with reoperation are superior in experienced centers, however, and typically these operations should be performed only by surgeons experienced in re-operative repair . If there is concern for ischemia, perforation or gross spillage, however, an open approach may be warranted . Important key steps relating to re-operative paraesophageal hernia repair will be discussed in this section (Table 16.2).
Key operative steps in the management of recurrent paraesophageal hernia repair
Pre-operative antibiotics, VTE prophylaxis, placement of urinary catheter
Veress, direct optical, or open entry per surgeon preference. Preliminary placement of liver retractor with re-adjustment after adhesiolysis
Establish plane between caudate lobe and pre-aortic fascia continuing on to right crus
4. Hiatal dissection
Proceed from anterior rim freeing up left and right rim of hiatus and stomach from retroperitoneum
5. Identification/preservation of vagus nerves
Nerves are at risk due to displacement at hiatus, must take care dissecting the 12 and 6–7 o’clock positions. Identify nerves on proximal esophagus more easily and follow distally
6. Takedown of previous fundoplication
Divide previous fundus, take down both anterior and posterior wings of fundus and remaining attachments must be divided. Restore normal anatomy and investigate for injury
7. Crural closure
Determine amount of tension on crus and close primarily with mesh overlay. May choose to perform diaphragmatic relaxing incision with PTFE bridge
8. Intraoperative endoscopy
Identify true GEJ by applying pressure with blunt grasper and correlating with intra-luminal findings. Check for injury using insufflation and leak test
9. Evaluation of esophageal length
Complete hiatal mobilization and retract GEJ anterior towards hiatus and measure intra-abdominal length. Utilize lengthening procedure or Hill fixation sutures if less than 2.5 cm
Perform full or partial fundoplication depending on surgeon preference with or without gastropexy
It is important to communicate with anesthesia regarding the preparation of the patient for the operating room, including the expected duration of the case and the potential for higher than usual blood loss or the need to convert to open surgery. Pre-operative antibiotics are given, particularly given the higher risk of enterotomy, along with subcutaneous heparin for venous thromboembolus prophylaxis . A urinary catheter is used routinely for urine output monitoring given the unknown expected length of re-operations. If the patient has any other concerning comorbidities or invasive hemodynamic monitoring is desired, a radial arterial line may be placed.
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Once the patient is positioned, the abdomen is entered and insufflated. If there are concerns about extensive adhesions, an open entry approach can be performed. There is little difference, however, between the safety of entry method even in the setting of a re-operation. A veress needle or direct optical entry can be used for insufflation without any difference in rate of complications . We have found left subcostal veress needle insertion followed by optical entry to be highly reliable and safe even following prior upper laparotomy for peritonitis . In the presence of extensive adhesions, a second port is placed wherever access can be obtained following initial entry and adhesions are progressively divided until further ports can be placed.
Once the abdomen is insufflated, a liver retractor is preliminarily put into place. It will likely need to be adjusted once typical adhesions between stomach and liver are divided. General adhesiolysis is performed to free the working space in the upper abdomen, making sure to avoid any bowel or other intra-abdominal viscera. If bowel is injured during the taking down of adhesions, a repair with interrupted 3-0 silk suture or a two-layer closure with inner absorbable suture is appropriate. Once all gross adhesions are divided, the dissection of the hiatus is started inferiorly between the stomach and the left lobe of the liver. Care must be taken to avoid starting or extending so inferiorly that the hepatic artery or bile duct structures are at risk. The initial goal should be establishing a plane between the caudate lobe and the left aspect of the pre-aortic fascia/left crus, as this plane will take one safely upward to the right aspect of the hiatus and right lateral crus (Fig. 16.5). There are usually adhesions from the previous surgery around this area and it is important to free up the plane from medial to the caudate lobe to the point that the inferior vena cava can be visualized and protected, being careful not to injure the vessel. Once this plane is freed, the right crus can be identified and the hiatal dissection begun.
Establishing the plane between the caudate lobe and the stomach and pre-aortic fascia. The inferior vena cava must be visualized and protected, being careful not to injure the vessel. Once this plane is freed, the right crus is identified and the hiatal dissection begun
From this point the dissection is performed from the aspect which is most clear and expedient, and this will continue to change throughout the dissection. Typically we begin along the anterior rim of the hiatus defining the plane between the crus and the edge of the stomach. The left anterior aspect of this dissection can be difficult and it is often helpful at this point to move to the left posterior aspect of the dissection, freeing the stomach from the retroperitoneum and working posteriorly and medially as far as possible. This will gain access to the posterior-left aspect of the hiatus which can then be followed anteriorly. The right posterior dissection can be particularly challenging if the stomach is densely adherent to the pre-aortic fascia and the plane of dissection is not clear. This may require bold dissection with the risk of enterotomy.
One of the most important points in redo hiatal hernia surgery is identification and preservation of the vagus nerves. Because of adhesions, the location of the nerves often deviates from normal anatomy. Particular care must be taken when dissecting at the 12 o’clock and the 6–7 o’clock positions around the hiatus. The anterior vagus nerve may be adhered anteriorly to the pericardium and can be inadvertently damaged while taking down the hernia sac. It is also at risk in the region of the GEJ. The posterior vagus nerve can be adhered posteriorly along the aorta to the decussation of the left and right crura and can be easily injured while dissecting the esophagus posteriorly. During re-do operations, scar tissue and adhesions around the hiatus and prior fundoplication make vagal identification difficult, and the nerves are best identified proximally along the esophagus in the mediastinum and followed distally towards the fundoplication.
Once the hiatus has been freed and vagus nerves are identified and preserved, the previous fundoplication can be taken down. It is important to restore the stomach and especially the fundus to its normal anatomic state in order to correctly identify landmarks and fashion a new fundoplication. Failure to completely un-do the prior fundoplication will likely result in another incorrectly performed fundoplication and high likelihood of failure. Once the hernia is reduced and the fundoplication can be visualized, it is helpful to slide a grasper into the inferior portion of the fundoplication opening to develop a plane (Fig. 16.6). After this plane is developed and enlarged, the fundus to fundus connection can be divided. If there is a clear demarcation, an energy device can be used for the division. If there is difficulty identifying the fundo-fundal plane with high risk of a gastric injury, a linear cutting stapler may be used. After division, the remaining fundal attachments are taken down carefully to avoid the vagus nerves which will run deep to the fundal wings anteriorly and posteriorly. The most difficult dissection is often in taking down the attachments between posterior fundus and lesser curvature. There are often additional subtle adhesions in the region of the angle of His which must be divided.
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