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S. K. Mittal
43
In this chapter we will review various controversies in regard to technical aspects of hiatus hernia
repair. While the debate is in no matter totally
settled, we have attempted to present a succinct
review of literature followed by a brief commentary to reect our opinion.
43.1 Open Versus Laparoscopic
Hiatus Hernia Repair
Hiatus repair with reduction of viscera at the time
of fundoplication is accepted as standard practice.
Elective repair is indicated for symptomatic type 1
and almost all type 2, 3, and 4 hiatus hernia. Rudolf
Nissen rst described Nissen fundoplication as an
open transthoracic procedure; however it can also
be performed via laparotomy and remains the
quintessential standard fundoplication. Other open
transthoracic (Belsy repair) and transabdominal
(Toupet) fundoplications have subsequently been
described. Advent of laparoscopic cholecystectomy
in the late 1980s laid way for induction of laparoscopic hiatal surgery. Laparoscopic fundoplication
was rst described by Delmangae in Belgium and
soon gained popularity worldwide. Initial technical
hurdles such as optics, short gastric division, suturing, and knot tying were sequentially overcome
with technological advancements. is allowed for
laparoscopic surgery even for large hiatus hernias.
First laparoscopic paraesophageal hernia was
described by Cuschieri etal. in 1992 [1]. Signicant
increase in volume of anti-reux surgery was
reported in the late 1990s.
e euphoria was soon subdued by poor surgical outcomes. Laparoscopic fundoplication and
especially large hiatus hernia repair are technically challenging procedures and require
advanced skills but have a steep learning curve.
An unacceptably high recurrence rate (42%)
reported by Hashemi etal. for laparoscopic paraesophageal hernia repair questioned its role and
advocated persistence with open procedure [2].
A meta-analysis of 12 prospective trials found
a risk reduction of 65% for complications in laparoscopic anti-reux surgery as compared to open
cases. Additional advantages stressed upon were
shorter hospital stay (by 2.68 days) and time to
return to activity (by 7.75days) in laparoscopic
surgeries with comparable rates of treatment failure when compared with open group [3]. Others
have also stressed upon the advantage of shorter
hospital stay and rapid recovery [4]. In one of the
earliest studies published in 1998, comparing
open vs laparoscopic approach for paraesophageal hernia repair, laparoscopic surgery patients
showed signicantly lesser requirement for ICU
care and pain medication and had earlier start of
oral intake and discharge [4]. However authors
report signicantly longer operative time with
laparoscopic approach [3, 4]. Karmali et al.
reported similar ndings with longer operative
time for laparoscopic repairs though associated
with shorter hospital stay and fewer operative
complications (22% vs 53%, P<0.01) [5]. A large
multicenter study of more than 2700 patients
reported similar results along with signicantly
lower 30-day readmission rates and overall costs
for laparoscopic surgery [6]. ey reported a signicantly lower in-hospital mortality even in
obstructed/strangulated paraesophageal hernia
cases for laparoscopic cases compared with open
cases (1.5% vs 6%; p<0.01). Several other authors
have shown favorable short-term outcome following laparoscopic HH repair [4, 7–9].
Complication rates as high as 37% have been
reported for laparoscopic repairs [10] in literature, but recent major trials report that with
improved laparoscopy techniques and experience,
overall complication rates have decreased to as
low as 2.7–3.8% for laparoscopy compared to
8.4% in open cases [5, 6, 11]. Overall 30-day mortality for laparoscopic anti-reux procedures, in a
review of 7531 patients, was reported to be as low
as 0.19% [11]. irty-day mortality for patients
younger than 70years of age was almost negligible
(0.05%), while it was acceptably low for those
above 70 years of age too (0.8%, p < 0.0001).
Nguyen et al. compared the two groups aer
adjusting for severity of illness and still found
laparoscopic repairs to have signicantly lower
hospital stay (3.1 vs 6.6days) and requirement for
ICU (10.4% vs 29.3%) as well as lower 30-day
readmission rates (1.3% vs 3.1%) compared with
open repair [6]. Despite these reports, the main
focus against laparoscopic repair comes from the
signicantly higher recurrence rates in long-term
follow-up and requirements for redo surgery of
up to 80% [3]. Experienced surgeons have
reported recurrence rates of 23–42% aer laparoscopic surgeries [7, 12, 13].
e risk of failure (anatomic, symptomatic, or
radiographic recurrence) of hiatus hernia repair is
one of the major factors against laparoscopic
Comparisons ofMethods at Hiatal Hernia Repair
441
43
approach. e steep learning curve could be considered one of the major reasons. e reported
recurrence rates widely vary from 7% to as high as
44% aer laparoscopic repairs [7, 12, 14, 15], while
in comparative studies by same group of surgeons,
open repairs are found to be associated with 9–23%
recurrence rates [7, 12, 15]. A meta- analysis on
recurrence aer laparoscopic repair of paraesophageal hernia, published in 2007, compared 13 studies and reported an overall clinical recurrence rate
of 14% in long-term follow-up for any type of laparoscopic procedure [16]. Recurrence, based on
follow-up esophagograms, was reported to be
25.5%. While no laparoscopic study has come close
to radiographic 4% recurrence rate reported by
Maziak et al., several reports with less than 10%
radiographic recurrence have been published [17].
Authors’ opinion: Laparoscopic hiatus hernia
surgery has come a long way since 1990s, thanks
to improved skill set, training process, technical
advances, and perioperative control of risk factors
(i.e., retching). e symptomatic recurrence is
signicantly lower. While the purist may use
radiological recurrence rate to argue against laparoscopy realist would counter with signicant
patient specic advantages of laparoscopic surgery and irrelevance of small asymptomatic
recurrence. Indeed, the authors concur with
recently published SAGES guidelines that laparoscopic hiatus hernia repair in experienced hands
is as good as open procedure and is associated
with lower perioperative morbidity. In our opinion laparoscopic repair should be the rst choice
for all hiatus hernia repairs when expertise is
available.
43.2 Partial Versus Complete
Fundoplication
DeMeester etal. popularized the short and oppy
360° Nissen fundoplication as the ideal fundoplication with good symptom relief without excessive dysphagia [18]. Side eects such as gas bloat
and dysphagia have led some to recommend partial fundoplication (anterior or posterior) as alternate options.
ere has been an ongoing debate on the comparison of partial posterior 270° (Toupet) fundoplication vs complete 360° Nissen fundoplication.
While many authors support partial wrap in view of
proposed fewer side eects like dysphagia [19, 20],
there have been concerns regarding purported
higher risks for recurrent disease [21–23]. While
most trials have presented a short-term follow-up
[21–24], two recent randomized controlled trials
comparing laparoscopic Nissen 360° wrap with
Toupet partial 270° wrap, authors found no signicant dierence in improvement of symptoms,
recurrence, and patient satisfaction in a long-term
follow-up [25, 26]. Higher postoperative wrap pres-
sures in Nissen group did not translate into higher
dysphagia. Fernando etal., in their study on 206
patients, reported similar early outcomes aer partial vs complete wrap. ey found signicantly
higher requirements for PPIs, worse longer satisfaction among patients, and higher dysphagia in partial wrap (Toupet) group as compared to complete
wrap (Nissen) group [27].
In a more recent randomized controlled trial
by Mardani etal. [28], studying 137 patients and a
mean follow-up of 18years, complete and partial
wraps did not dier signicantly in control of
heartburn (80% vs 87%) and acid regurgitation
(82% vs 90%), respectively. Both groups showed
similar rates of long-term side eects including
dysphagia scores, bloating, and atulence. e
higher rate of atulence seen in the early postoperative period aer complete fundoplication
decreased over time.
Kamolz etal. studied the subjective and objective quality of life (QoL) between two groups.
ey found signicant improvement in QoL of
patients with GERD aer either surgery and
found no signicant dierences in QoL between
Nissen and Toupet fundoplication groups. Only
reported dierence was frequency of mild transient dysphagia seen in Nissen group [29].
Some authors have proposed an anterior fundoplication wrap (90–80°) to replace the 360°
wrap or 270° partial posterior wrap. Although
they were proposed in view of reducing the postprocedure dysphagia, they have been found to be
associated with a higher postoperative recurrence
of reux [30–35]. A recent meta-analysis comparing short- and long-term outcomes following a
complete Nissen fundoplication vs anterior 180°
fundoplication included ve RCTs [36]. At short
term (1 year post surgery), dysphagia scores,
bloating, atulence, and inability to belch were
signicantly lower for anterior wrap and continued to remain lower at long term (5 years post
surgery). Heartburn, regurgitation, endoscopic
dilatation, need for redo surgery, need of PPIs,
442
S. K. Mittal
43
and patient satisfaction did not dier signicantly
between the two groups at short and long term.
However, a meta-analysis of seven RCTs, done by
the same research group, comparing anterior vs
posterior partial wraps favored posterior wraps
with lesser esophageal reux symptoms (8% vs
21%), esophageal acid exposure time (0.8% vs
3.3%), and reoperation (4% vs 8%) as compared
with anterior wraps [35]. While the two groups
did not dier signicantly in short-term outcomes, long-term outcomes in posterior fundoplication group had signicantly lower rates of
persistent heartburn (14% vs 31%) and reoperation rates in long-term follow-up (5% vs 10%).
ere were no dierence in dysphagia and gas
bloating symptoms.
Recently, Svetano etal. reported no dierence
in use of medication, symptoms, and quality of life
in a cohort of patients with and without fundoplication with intrathoracic stomach repair [37].
Author’s opinion: Excellent patient centered
outcome with both partial and total fundoplications have been reported by several centers. We
rarely use anterior partial anti-reux procedure
except ones with myotomy. Posterior partial or
complete fundoplication should be performed
based on surgeon’s preferences.
43.3 Mesh Versus Non-mesh
Crus Closure
Recurrent hiatus hernia is the proverbial Achilles
heel of benign foregut procedures. Recurrent hiatus hernia is noted on up to 40% of patients aer
PEH repair if routine contrast radiography is
undertaken. However majority of these patients
are asymptomatic. But recurrent hiatus hernia is
noted in up to 70–80% of patients undergoing
reoperative foregut surgery aer previous antireux procedures.
Given the success of mesh repairs for inguinal
and ventral hernia, the use of mesh in hiatoplasty
was pursued enthusiastically. Unfortunately, several complications including the need for esophagogastric resection were reported, and the role of
mesh reinforcement is being closely relooked.
Ever since the use of prosthetic material for
hiatal closure, rst described by Kuster and Gilroy
in 1993 [38], there have been controversies revolving around selective or liberal use, shape and
material of the prosthetic meshes being used, as
well as the technique of placement. Major worry
by most authors in using a prosthetic reinforcement in hiatal closure is the risk of visceral adhesions, erosion, and mesh migration along with the
wrap to intrathoracic cavity [39]. Granderath
etal. reported that mesh hiatoplasty was associated with signicantly lesser rates of postoperative wrap migration (0.6% vs 6.1%) compared
with non-mesh reinforced cases, while early dysphagia was signicantly higher with mesh group
(35.3% vs 19.8%) [39]. However, there was no
signicant dierence in dysphagia between two
groups at 1-year follow-up and later.
Oelschlager et al. in their prospective randomized trial reported a radiologic recurrence
rate of 9% at 6-month follow-up in the biological
mesh group vs 24% in the non-mesh group [40].
However, with follow-up at 5years, there was no
dierence in rate of recurrence [40]. What was
surprising in the study was greater than 50%
recurrence in both with mesh and without mesh
groups, even though most recurrences were
asymptomatic. Another RCT of 72 patients
reported the use of PTFE mesh to be associated
with higher costs and longer operative time but
no dierence in hospital stay or complications
compared with posterior suture cruroplasty [41].
ey reported all recurrences of hernia in the
non-mesh group while none in mesh group.
ough the authors favored the use of PTFE
mesh, use of polypropylene mesh was discouraged in view of high propensity of polypropylene
material to cause erosions and strictures around
the esophagus (in both open and laparoscopic settings) [10, 42, 43] along with erosion of other viscera, mesh extrusion, and stulization.
Among comparison of various mesh materials
used for hiatal hernia repair, a survey conducted
by SAGES reported that the highest rates of failure of surgical repair were seen with biomaterial,
while composite meshes had the least rates of failures [44]. Most common mechanism of failure
was a loose hiatoplasty or technical failure of
mesh anchorage. Complications were reported
higher with PTFE meshes compared with
polypropylene and bioprosthetics.
Another survey conducted by SAGES in 2012
about the types of hiatal hernia repairs done by
surgeons and use of mesh vs non-mesh repairs,
9% surgeons reported to use mesh in all cases
[45]. Another 15% reported to use mesh in more
than 50% of their cases. Among surgeons doing
Comparisons ofMethods at Hiatal Hernia Repair
443
43
>20 HH repairs per year, 23% used mesh in
majority of their cases. However, 23% never used
mesh reinforcement, while 29% used mesh in less
than 10% of their cases. Among the surgeons
using mesh, one third preferred nonabsorbable
meshes over absorbable mesh.
However, there is signicant paucity of comparative studies and randomized controlled trials
to compare primary suture cruroplasty with
absorbable and nonabsorbable mesh reinforcement for hiatal hernia repair.
According to the current SAGES guidelines,
there is strong evidence that the use of mesh for
reinforcement of large hiatal hernia repairs leads to
decreased short-term recurrence rates [46].
However, there is inadequate long-term data on
which to base a recommendation either for or
against the use of mesh at the hiatus. Complications
are reported with all types of meshes, and the common and most dreaded complications are mesh
erosion, esophageal stenosis, pericardial tamponade, and eusion. SAGES guidelines recommend
avoiding bridging synthetic meshes as they are
found to have higher chances of mesh erosions [46].
Author’s opinion: While recurrent hiatus hernia continues to vex the surgeons, most are
asymptomatic. Routine mesh hiatoplasty is denitely not the answer. Complications associated
with mesh closure are frequently associated with
the need for esophagogastric resection. Mesh use
should be very limited if at all and used only by
surgeons with expertise in hiatus hernia surgery.
43.4 Anterior Versus Posterior
Cruroraphy
e role of hiatoplasty (also called cruroplasty or
cruroraphy) is indispensable as unacceptably high
rates of recurrent paraesophageal hernias are seen
in patients not undergoing closure of hiatus [47–
49]. Posterior cruroraphy has been the cornerstone
of crus closure from both thoracic and abdominal
approach whether done laparoscopic or open.
However, there is paucity of literature comparing
the outcomes following anterior vs posterior cruroplasty (hiatoplasty) for hiatus hernia.
e posterior hiatoplasty is the most common
approach by most surgeons and is considered standard for hiatal hernia surgeries with acceptable
outcome and good clinical control of symptoms
[18, 50, 51]. However, Watson et al. emphasized
that a posterior wrap nonphysiologically displaces
the esophagus too anteriorly and signicantly contributes to dysphagia [52]. e same group published a double-blinded RCT in 2002 showing no
need of redo surgical interventions in patients who
underwent anterior cruroplasty compared with
almost 10% posterior cruroplasty patients requiring second surgical procedure [53]. ey reported
no dierence in postoperative dysphagia, relief of
heartburn, overall satisfaction at 6-month followup, and likelihood of early postoperative paraesophageal herniation. ey also reported hiatus
being too tight a more common cause requiring
reoperation than fundoplication problems (2% vs
<1%). However, they attributed the dierence in
anterior and posterior cruroplasty to the possible
type II error considering the earlier reports by the
same group reported an incidence of reoperation
being 1% in posterior cruroplasty group [54, 55].
e same research group published the long-term
(5years) follow-up on the previous RCT in 2008
[56]. Anterior hiatal group showed better control
of symptoms, while the overall satisfaction and
postoperative dysphagia were similar in two
groups. Posterior hiatal repair group showed
higher need for “dysphagia-related” redo surgical
intervention than anterior hiatal repair group
(14.5% vs 4.3%, P=NS). Dierence was signicant
among two groups with respect to the need for
redo intervention “for any cause” (4.3% vs 20%,
P=0.011). In yet another recent RCT with a longterm follow-up (10years or more for 93% patients),
anterior hiatal repair group reported signicantly
less dysphagia to lumpy solid foods (14% vs 39.5%,
P=0.01) as compared with posterior hiatal repair
[57]. ey did not report any signicant dier-
ences in reux symptoms, need for anti-reux
medications, and overall satisfaction to surgery in
long term.
us, although there is a paucity of data for
the comparison of these two groups, anterior
cruroplasty seems more promising in reducing
current rates of postoperative dysphagia as seen
aer posterior cruroplasty.
Author’s opinion: While posterior cruroplasty
is the standard repair option for hiatus repair,
there is a concern to displace the esophagus anteriorly resulting in dysphagia. Additionally, the
posterior crus closure can sometimes not be
achieved without tearing of the crus. In these situations, anterior cruroplasty is needed. We have
approached these situations by closing the crus
444
S. K. Mittal
43
more in an anterolateral direction rather than a
true 12 o’clock anterior location. is results in
the nal crus closure to look like an inverted L
with the esophageal opening at the angle.
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SA, Smith SL.Paraesophageal herniation as a complication following laparoscopic antireux surgery. J Gastrointest Surg. 1999;3(1):95–9.
50. Kelly J, Watson DI, Chin K, etal. Laparoscopic Nissen
fundoplication: clinical outcomes at 10 years. J Am
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51. Dallemagne B, Weerts J, Markiewicz S, et al. Clinical
results of laparoscopic fundoplication at ten years
after surgery. Surg Endosc. 2006;20:159–65.
52. Watson DI, Jamieson GG, Mitchell PC, Devitt PG, Britten-Jones R.Stenosis of the esophageal hiatus following laparoscopic fundoplication. Arch Surg.
1995;130(9):1014–6.
53. Watson DI, Jamieson GG, Devitt PG, Kennedy JA, Ellis T,
Ackroyd R, etal. A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair. Arch Surg. 2001;136(7):745–51.
54. Watson DI, Jamieson GG, Pike GK, Davies N, Richardson M, Devitt PG. Prospective randomized doubleblind trial between laparoscopic Nissen fundoplication
and anterior partial fundoplication. Br J Surg.
1999;86(1):123–30.
55. Watson DI, Pike GK, Baigrie RJ, Mathew G, Devitt PG,
Britten-Jones R, et al. Prospective double-blind randomized trial of laparoscopic Nissen fundoplication
with division and without division of short gastric vessels. Ann Surg. 1997;226(5):642–52.
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57. Chew CR, Jamieson GG, Devitt PG, Watson DI.Prospective randomized trial of laparoscopic Nissen fundoplication with anterior versus posterior hiatal repair: late
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New Technologies
inHiatal Hernia Repair:
Robotics, Single Port
andSujith Wijerathne
44.1 Introduction – 448
44.2 Indications – 448
44.3 Preoperative Preparation – 449
44.3.1 SILS Hiatal Hernia Repair – 449
44.4 Technical Diculties – 452
447
44
44.5 Tips andTricks – 452
44.5.1 Robotic Hiatus Hernia Repair – 452
44.5.2 Technique ofHiatal Hernia Repair – 453
44.6 Conclusion – 455
References – 455
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_44
44
448
D. Lomanto et al.
44.1 Introduction
Hiatus hernia (HH) involves herniation of contents of the abdominal cavity through the diaphragm into the mediastinum. e rst
description of hiatus hernias dates back to 1853
by a physician, Henry Ingersoll Bowditch [1].
en in 1926, Ake Akerlund, a Swedish radiologist, coined the term hiatus hernia. He further
classied HH into three types, which is still in use
[2]. HH occurs due to enlargement of the diaphragmatic aperture, which then allows herniation of abdominal contents into the mediastinal
cavity, most common organ being the stomach
but may also contain other viscera like the colon
or spleen. Until the 1950s the relationship of HH
with gastroesophageal reux disease (GERD) was
not appreciated. While the type I or sliding HH
are more commonly associated with GERD, the
larger types II–IV or paraesophageal hernias
(PEH) are associated with gastric volvulus, leading to mucosal ischemia, strangulation, and gastric obstruction.
The appreciation of the physiological link
between HH, GERD, and other problems has
changed the approach toward HH surgery from
simple repair to restore the anatomy to restoring the physiology. Ever since Nissen and Belsey
described their revolutionary techniques, several modifications and innovations have been
published in literature. Essential principle for
these modifications is physiological restoration.
Since the advent of laparoscopic cholecystectomy in 1980s, the philosophy to be less invasive
has led to the exponential growth of minimal
access surgery. Laparoscopic hiatal hernia repair
is the standard for treating HH today. Compared
to laparotomy, laparoscopic hiatal hernia repair
oers all the well-established benets of a minimally invasive surgery, such as reduced postoperative pain, faster recovery, shorter hospital stay,
and decreased risk of wound infection which
favor its continuing use. Combined together it
allows early return to routine life and work.
Smaller scars give better cosmesis and hence
improve patient satisfaction [3–6].
Today, technological advances in both diagnosis and treatment have revolutionized surgical
practice in hiatal hernia. With a view to further
reduce the trauma of surgical access and perform
more complex surgical tasks, researchers and
surgeons have invested in concepts of reduced
port laparoscopic surgery (RPLS), single incision
laparoscopic surgery (SILS), natural orice transluminal endoscopic surgery (NOTES), and
robotic surgery. HH repair techniques also have
attempted to incorporate these novel techniques
into practice.
In this chapter, we focus on the role of SILS
and robotics in hiatal hernia surgery, indications,
instrumentation, surgical steps, and postoperative
care.
44.2 Indications
e advent of minimal invasive surgery has led to
an increase in the number of operations for hiatal
hernia. is coupled with widespread availability
of endoscopy, 24-h pH studies, manometry,
impedance studies, and radiological studies have
helped in diagnosing patients who may benet
from surgery. SAGES guidelines provide a good
basis for investigating patients with reux disease
and hiatal hernia [7, 8]. Only those investigations
that will help in clinical decision-making or alter
the treatment plan can be performed.
Most surgeons consider single incision laparoscopic surgery (SILS) or robotic surgery to be
more complex techniques requiring longer learning curve. But with increasing experience, many
surgeons have today readily accepted these novel
techniques.
e indications for SILS or robotic surgery for
HH are similar to laparoscopic hiatal hernia
repair.
As per the SAGES guidelines oer surgery to:
1. Type I hiatal hernia with GERD.
2. All symptomatic PEH.
3. Elective repair of completely asymptomatic
PEH routinely is not indicated. Decision-
making is based on patient’s age and comor-
bidities (strength of evidence weak as per
guidelines).
4. Acute gastric volvulus.
5. Asymptomatic PEH with anemia.
In fact on careful history taking, most patients
will elicit some symptoms of reux disease or
obstruction. About 14% of asymptomatic PEH
patients every year will develop symptoms [9, 10],
and less than 2% patients per year will need emergency surgery due to acute symptoms [10–14].
New Technologies inHiatal Hernia Repair: Robotics, Single Port
449
44
Patients unt for general anesthesia and intractable coagulopathy are contraindications for any
laparoscopic surgery. Robotic surgery may give an
advantage in large hiatal hernia and patients with
high BMI.Large paraesophageal hernia (types II–
IV), long history with esophageal shortening, BMI
>30 kg/m2, and acute presentation are presently
not strict exclusion criteria for SILS or robotics but
should be done by an experienced surgeon.
A beginner should preferably operate on the
following patients:
5 Patients undergoing elective hiatal hernia repair
5 Patients with type I HH
5 Patients with BMI<30 kg/m
5 Patients t for general anesthesia
5 Patients who can safely withstand longer
operative times
A beginner should preferably not perform SILS
on the following patients:
5 Patients with acute presentation (HH with
bleeding, gastric volvulus, features of strangu-
lation, types II–IV, esophageal shortening)
5 Patients with previous upper abdominal
surgery
5 Patients who are obese (BMI>30 kg/m2)
5 Patients who are unable to withstand longer
operative times
With increasing expertise in SILS, most of these
technical diculties will be overcome.
More recently, development of robotic surgical system, a novel technology, is becoming popular among minimal invasive surgeons. e
suggested advantages are three-dimensional
vision, abolition of tremors, better motion scaling, and higher degrees of freedom due to intuitive movements. In the end result, it allows
surgeon to perform complex maneuvers which
are dicult to master in standard laparoscopy.
However, actual benets to patients due to use of
this technology are still controversial. While its
benets are clear for complex procedures, its use
is still not justied for routine simple surgery. e
complexity observed particularly during large
and complex varieties of PEH repair and in obese
patients with PEH during laparoscopic repair can
be considered an indication for use of this novel
technology. It may also help a beginner to overcome some technical diculties to perform complex tasks using a robot, which he may nd
dicult during standard laparoscopy or SILS.
2
44.3 Preoperative Preparation
Always counsel patient’s so that they understand
the exact nature of disease process and its treatment. Explain the patient in detail the various
available modalities of treatment with their possible benets and risks. Long-term results of surgery,
recurrence, and failure rates should be explained.
Take a proper consent for SILS or robotic surgery. Counsel the patient about the possibility of
conversion to standard laparoscopy/open surgery
in case of technical diculties, for patient’s safety
and well-being.
Apart from the routine workup and investigations, a coagulation prole must always be performed
to rule out intractable coagulopathy, which is an
absolute contraindication for laparoscopic surgery.
Preoperative shaving may be done based on
individual surgeon preference but should always
be performed on the operative table. In cases
when the surgery is expected to be of a longer
duration and during emergency, the bladder is
catheterized. An antibiotic prophylaxis is always
administered before anesthesia.
Always perform a team time-out between surgeon, operation nurse, and anesthesiologist before
making the rst incision. It is mandatory to
reconrm the patient’s name, diagnosis, availability of instrumentation/devices, and the planned
procedure.
44.3.1 SILS Hiatal Hernia Repair
Operation Theater Layout
e patient is placed in supine position on a split
leg table. Both arms are tucked by the side and
legs apart. Properly secure the patient to the table.
e surgeon stands in between the patient’s legs;
the camera assistant stands on the patient’s right
with the monitor placed on le side of the patient’s
head (. Fig.44.1). If two monitors are available,
place one on either side of the head. An additional
assistant may stand on the patient’s le in selected
cases. e scrub nurse stands on the le side. Give
a steep reverse Trendelenburg position as this
helps exposure of the hiatus.
Instrumentation
Irrespective of approach used, the surgeon should
be able to perform the procedure safely. e key
factor when using any device or instrument is its
44
450
D. Lomanto et al.
ANAESTHETIST
MONITOR
ASSISTANT FOR
CAMERA
SURGEON
. Fig.44.1 Operation theater layout SILS
. Fig.44.2 Instruments
SILS
MONITOR
SECOND ASSISTANT
safety in patients. Instrumentation in single-port
surgery should give the surgeon similar degrees of
freedom as in standard multiport laparoscopic
surgery. In the last decade, due to research in
instrument technology, variety of articulating
instruments (pre-bent, reticulating, or articu-
lated/wristed) (. Fig.44.2) and devices have been
developed. e devices range from conventional
laparoscopic instruments to more sophisticated
ones to simple self-made devices, which give
access to more instruments inside conned space.
Other important factors are simplicity of the
device, cost, easy availability, and reusability.
A variety of single-port access devices are available in practice. ese vary from simple self- made
devices to complex devices with multiple access
ports. ese include SILS port (Covidien, USA),
GelPort (Applied Medical, USA), X-Cone (KARL
STORZ, Germany), Uni-X (Pnavel Systems Inc.,
USA), TriPort (Advanced Surgical Concepts,