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Chapter1

ParaesophagealHernia Repair:Laparoscopic Technique



JohnG.HunterMarkJ.Eichler

DEFINITION

■ Formillennia,theexistenceofhiatalherniaswaswellknown.Firstdescribedby HenryBowditchin1853,andlaterin1951officiallybyPhilipAllison,the paraesophagealhernia(PEH)presentsaphysiologiclinktorefluxesophagitis, ulceration,stricture,andotheresophagealpathology.

1,2

■ Ofthefourtypesofhiatalherniasknowntoday,95%ofincidenceresideswith thetypeIorslidinghiatalhernia,whichtypicallycanbemanagedmedically withgastricacidsuppression.Theremainingthreetypesarelumpedas “paraesophagealhernias.”TheseincludethetruePEH(typeII),combined slidingandparaesophageal(typeIII),andextragastric(typeIV)(FIG1). Withtheadventofmodernantirefluxsurgery,failedfundoplicationoverlaps withthisclassification(FIG2).Furthermore,disruptionoftheesophageal hiatusforotherdiseaseprocesses,suchasesophagectomy,potentiatesthe PEH,especiallytypeIV.

■ Thischapter,inconcertwithotherproceduressuchasfundoplicationand esophageallengthening(Collisgastroplasty),willdealwiththesurgical managementofPEHtypesIItoIV,whichanatomicallymayalsoencompass redofundoplication.Principlesofrepairincludedefinitionofanatomyand symptoms,safereductionofabdominalorgansbacktotheperitonealcavity, excisionoftheherniasac,closureofcrura(withorwithoutmeshrepair), evaluationofintraabdominalesophageallength,andanantireflux procedure.

3,4

PATIENTHISTORYANDPHYSICALFINDINGS

■ NecessityforPEHrepairlieswiththepatientsymptomatology,medicalstatus, andchanceofobstructionorstrangulation.PEHscanencompasssymptomsof gastroesophagealrefluxdisease(GERD),whichincludestypicalsymptomsof heartburn,acidreflux,anddyspepsia.Incontrast,atypicalGERDsymptoms manifestaslaryngealandpulmonarycomplaintsofnoncardiacchestpain, dyspnea,poordentition,sinusitis,asthma,chroniccough,pneumonia,and halitosis.PEH-specificcomplicationsincludegastricvolvulus,incarceration, gastricoutletobstruction,andhighermortalitywhenperformedemergently. Earlystudiesonmortalityinthe1960sdemonstratedmortalityratesover50% forPEHswithassociatedgastricvolvulus,althoughmorerecentanalysis suggeststhatnumbertobeoverestimatedandisactuallymorelikelytobe under20%forsuchpatientsinduressfromPEH.

5,6

ForallPEHpatients, overallmortalityisunder1%andcansafelybeperformedwithalaparoscopic approacheveninthefaceofobstruction,gangrene,andsoforth.

■ IndicationsforPEHrepairthereforeshouldbetailoredtopatientswhoare symptomaticandmedicallylikelytosurviveanoperation.Ultimately,most patientswhohaveaPEHwillbecomesymptomatic.

3,5,6

IMAGINGANDOTHERDIAGNOSTICSTUDIES

■ Preoperativediagnosticstudieshelpdictatetherangeofelective,urgent,and emergentnatureofasymptomaticpatientwithaPEH.Inthosepatientswho areinextremis,theminimumworkupneededforurgentoremergentPEH repairisradiographicevidenceofincarceration,perforation,obstruction,or failedantirefluxsurgery.However,themajorityofpatientspresentinan electivemanner,andwethereforeadvocateforacompleteworkuptoassist preoperativeplanningofthesymptomaticpatientwithPEHbytheadditionof manometry,pHtesting,andendoscopytoruleoutpseudoobstructionor esophagealmotilitydisorders.

■ Chestx-ray:Atpresentation,whethertoanemergencydepartmentoraprimary carephysician’soffice,thechestx-raygivesquickandcost-effective informationtotheseverityofthePEH.Mediastinalgasbubblecanbeseenon plainfilmradiographyaswellasthepresenceofpneumoperitoneumor pneumomediastinum.

■ Esophagram:Thesupineanduprightplainfilmesophagramdemonstratesstatic anatomyandcanoftenlocatethegastroesophagealjunction(GEJ)inrelation tothediaphragmaswellasdeducethepresenceofrefluxondelayedfilms. Mucosalabnormalitiescanbeseenwiththismodalityaswell(FIG3A,B).

■ Computedtomography(CT):IndicationsforobtainingCTscansincludethe emergentpresentation,inconclusivebutworrisomefindingsontwo-

dimensionalradiography,andPEHtypeIV(FIG4).CTaidsthepreoperative planningbyalertingthesurgeontotheextentofskinpreparationand positioningforoperativerepairbutisnotnecessary.

■ Upperendoscopy:Allpreoperativepatientsshouldundergoupperendoscopyif possible.Byvisualizationoftheesophagealandgastriclumen,neoplasm, Barrett’sesophagus,andesophagitiscanbebiopsied,and,incase esophagectomyiswarranted,providehistologicdiagnosis.Furthermore, anatomiclandmarkscanbeseensuchasthedistancebetweenthehiatusand theGEJaswellasthesizeofthehiatalhernia.

■ Manometry:Severalstudiesofbenignesophagealdisordersconfirmtheuseof preoperativemanometry.

3,8

Distalesophagealpressuresgreaterthan30 mmHgindicatefavorableoutcomeofresponsetofundoplication,which, accordingtosomesurgeons,isathresholdforperformingacompleteversus partialwrapfortheantirefluxcomponentofthePEHrepair.Manometryalso rulesoutprimaryesophagealdysmotilityincludingachalasia,diffuse esophagealspasm,nutcrackeresophagus,hypertensiveloweresophageal sphincter(LES),andineffectiveesophagealmotility.Wedonotadvocate performingacompletefundoplicationforpatientswithesophageal dysmotilityorlowdistalesophagealpressures.

■ pHstudy:AlthoughthepreviousmodalitiesofthePEHworkupprovidearobust descriptionofthePEHpatient,pHstudiesprovidedataforthedecisionin failedantirefluxsurgerytodissectandredoapreviousfundoplication.Inthe settingofanegativepHstudy(bywayofDeMeesterscore<15),9a

“herniated”fundoplicationmayindeedbeintact,thussavingtheriskof tediousandunnecessaryredofundoplicationasacomponentofthePEH repair.

SURGICALMANAGEMENT

PreoperativePlanning

■ Allstudies,includingesophagram,esophagogastroduodenoscopy(EGD), manometry,andpHtestingshouldbereadilyavailableandreviewedpriorto andatthetimeofsurgery.Theesophagramshouldbedisplayedonaspareor dedicatedmonitorintheoperatingtheaterandEGDimagesbeloadedaswell forintraoperativereference.

■ Attentiontofinedetailofthemanometricreportmayavoidanunnecessaryand detrimental360-degreefundoplication,asacompletewrapmayworsen symptomsinthelightofthefollowingfindings8:

■

Severeesophagealdysmotility

■ VerylowresidualpostrelaxationLESpressureslessthan30mmHgduring wetswallow

Positioning

■ AnoperatingtablecapableofsteepreverseTrendelenburgpositionisrequired. Armsaretuckedatthepatient’ssidesbutcanbeout90degreesandsecured. Footboardsonasplit-legtablearemandatory,andapreproceduralreverse Trendelenburgtestisusedforsafetyconfirmationofpositioning(FIG5A).

■ Assumeextensivemediastinaldissectionwillbewarranted,andtherefore, pleuralcompromiseisafrequentoccurrence.Thesterileskinpreparation mustbewideenoughoneitherflankincasetubethoracostomiesare necessaryfromresultantpneumothorax.However,aredrubbercatheter between10and14Frmaybeplacedinawitnessedpleuraldefect intraabdominally,spanningthediaphragmtothehemithoraxinquestion.This reducestheresultantpneumothoraxandpeakventilatorypressureswiththe aidofloweringinsufflationpressuresaswellasanesthesia-assisted ventilatoryValsalva.

■ AfterVeressneedleinsufflationineitherthesupraumbilicalortheleftupper quadrant,trocarplacementensues.Fivetrocarsareusedforthelaparoscopic PEHrepair(FIG5B).Aftertheliverretractorandportsareplaced,thepatient ispositionedintosteepreverseTrendelenburgandthedissectionbegins.

Instrumentation

■ Asaforementioned,therecanbeuptoa20%enterotomyrateduringPEHrepair, especiallyduringredooperations.Therefore,extraordinarycareistantamount toestablishingsafedissectionplanes,especiallyneartheesophagus. Ultrasonicshearsarethemainstayofdissection(HarmonicAcecurved shears,Ethicon,Somerville,NJ),whereaswhenoperatingextremelycloseto organs,weadvocateswitchingtolaparoscopicscissorsaswellasblunt dissectiontoavoidthermalinjury.

TECHNIQUES

REDUCTIONOFTHEHERNIA

■ Towhateverextentpossible,reducethecontentsofthemediastinumpreviously backintotheabdominalcavitybyuseofboththeprimarysurgeon’shandsas wellastheassistant’swithatraumaticgraspers(FIG6).Notethattheremay bevariouslayerstothehiatalherniasac(FIG7).

INITIALHIATALDISSECTION

■ Itisusuallysafe,oncecountertractioniswellestablishedandreductionofthe entirePEHisattained,toinitiatedissectionontherightcrusdirectlytothe rightoftheesophagus,providingastartingpointforanteriorandposterior dissection.Anteriordissectionoccursina180-degreefashionanteriorlyand thentotheleftofthehiatus,justinaplaneimmediatelydeeptothe peritoneum/herniasac;anydeeperandthermalinjuryorperforationmight happentotheesophagus.Iftheherniacannotbecompletelyreduced intraabdominally,thenweadvocateanapproachfromtheleftcrus,anteriorly 180degreestotherightcrus(FIG8A,B),reasoningthatthepositionofthe unreducedPEHandtruedissectionplaneontheleftcanbemorereadily ascertained.TheresultantanteriordissectioncanbeseeninFIG9.

■ Posteriordissectionensuesfromtheoriginalstartingpointtotherightofthe esophagustofreetherightcrusposteriorlyanddeep,thenasmuchas possible,totheleftoftheGEJ.

SHORTGASTRICVESSELLIGATION

■ Beforecomplete360-degreedissectioncantakeplace,theshortgastricvessels mustbecompletelydissected,evenifapreviousproceduresupposedlytook place,assomesurgeonsselectivelyorincompletelyperformshortgastric takedown(FIG10A–C).Thisshouldbeperformedontheslowsettingofthe ultrasonicshears,asprematureligationmightallowincompletelyligated vesselstoretractintothegastrosplenicligamentuncontrollably.Although endoscopicsurgicalclipsmayhelp,itismoreefficacioustoregraspthe bleedingligamentandvesselsforultrasonicligation.Occasionally,depending onthesurgeon’sskill,anopenprocedureisnecessitated.

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