Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана

An upper GI contrast study is helpful to both establish a diagnosis of a paraesopha­geal hernia and to evaluate gross esophageal motility and length as well as the loca­tion and extent of the supradiaphragmatic stomach. Figure2 shows an upper GI study of a patient with a large type 3 hiatal hernia with organoaxial volvulus. This study can evaluate for volvulus and obstruction and give an assessment of the type of the hernia. Endoscopy should always be performed to measure esophageal length, amount of herniated stomach, amount of volvulus, and mucosal abnormalities including Cameron ulcers, Barrett’s esophagus, or neoplasms [11]. Patients with paraesophageal hernias are often older and may have symptoms warranting cardio­pulmonary evaluation prior to surgery. Esophageal manometry can be helpful to rule out esophageal motility disorders but is also often difcult to obtain in settings of large hernia and volvulus. Pressurization of the stomach against the distal esoph­agus within the chest may also create a falsely elevated integrated relaxation pres­sure and cause a patient to be misdiagnosed with EGJ outow obstruction. Cross sectional imaging in the form of computed tomography can also be helpful to iden­tify anatomy but is not required preoperatively (Fig.3).

All patients should undergo induction of general anesthesia with endotracheal intu­bation using techniques to prevent aspiration. The patient should be placed in either the supine position or on a split-leg table. The arms are secured on padded arm boards at a 90° angle to the body’s axis. A footboard is placed and the patient secured to the bed in anticipation of a steep reverse Trendelenburg position during the case. An orogastric or nasogastric tube can be placed as needed to decompress the stomach. Sequential compression devices should be placed on the lower legs bilaterally and subcutaneous heparin can be administered for deep vein thrombosis prophylaxis. A foley catheter can be considered for close monitoring of urine output if the procedure is emergent or the patient has multiple comorbidities. The skin of the abdomen should be widely prepped after hair has been clipped short using an atraumatic electric clipper. A single dose of antibiotics should be administered within 1h of incision [21].

sac and mediastinum will pay off here. This avascular plane can be dissected cir­cumferentially along the crura. Consistent retraction of the hernia sac toward the patients feet as dissection progresses will allow preservation of the peritoneum of the crura, and keep your dissection plane inverted into the abdomen for easy visual­ization. It will also prevent encroaching up on the crural muscle itself during repair, which allows for a more robust repair that includes intact peritoneum overlying the crura. This plane is avascular and thus bleeding is typically minimal. Bleeding dur­ing this dissection would indicate that either you are too deep within the mediasti­num or encroaching on the esophageal wall. In either case, care should be taken to reidentify the proper plane before progressing. In general, the left crural pillar is typically easier to dissect than the right (Fig.6). The right pillar has adjacent vascu­lature of the stomach (left gastric artery) which must be avoided during dissection to avoid compromising the gastric blood supply.