CHAPTER 5 Paraesophageal hernia
Step 1. Clinical anatomy
♦ The main topic of this chapter is the operative management of paraesophageal hernias, which can also be referred to as giant hiatal hernias. These are usually managed by a surgeon and often require operative repair.
♦ Paraesophageal hernias (PEHs) are characterized by the migration of the gastroesophageal junction and the upper stomach into the mediastinum.
♦ There is typically a large anterior hernia sac that is composed of the attenuated phrenoesophageal ligament and two smaller posterior sacs. The sac is bordered by the mediastinal pleura, pericardium, and the aorta.
♦ The configuration of the stomach within the sac of a PEH may also be described in terms of its rotation, if present, in the organoaxial or mesioaxial position.
Step 2. Preoperative considerations
♦ Patients often experience symptoms of heartburn and regurgitation because of the intrathoracic location of the gastroesophageal (GE) junction.
♦ Other frequently present symptoms include dysphagia, chest pain, and respiratory compromise, which are due to the mechanical effects of the herniated stomach in the mediastinum.
♦ The lining of the herniated stomach can develop deep ulcerations known as Cameron’s ulcers, which may cause occult blood loss. Some patients may not have any gastrointestinal symptoms but suffer only from chronic anemia. It is not rare for the diagnosis of PEH to be made in the workup for iron deficiency anemia.
♦ Occasionally, one encounters a patient with a PEH who is truly asymptomatic. The classic teaching has been that these patients should undergo repair to avoid the chance of strangulation. Because of the rarity of this event, combined with the known risks associated with elective repair, most patients can be managed with watchful waiting.
♦ Most patients with PEH are intermittently symptomatic. These patients should undergo elective repair by a laparoscopic approach if there is no contraindication.
♦ In the rare event of strangulation of the herniated stomach, chest pain and foregut obstruction are the usual associated presenting signs. Treatment of this condition requires vigorous resuscitation and urgent laparotomy. Partial gastrectomy and reconstruction may be necessary.
Patient preparation
♦ Patients with PEH need a broader preoperative evaluation than patients with GERD alone because they tend to be older and have more frequent cardiopulmonary conditions.
♦ In patients with significant preoperative nutritional deficiency or comorbidities that make operative repair too risky, endoscopic management may be best. One or sometimes two percutaneous gastrostomy tubes may provide gastric fixation and can also aid with postoperative nutrition.
Objective testing
♦ A barium swallow can be used to assist in determining anatomy and operative planning.
♦ Upper endoscopy helps to identify mucosal erosions as a source of gastrointestinal bleeding and can rule out Barrett’s esophagus and malignancy. This test should be attempted knowing that sometimes it is technically impossible to obtain.
♦ Esophageal motility study and 24-hour pH studies are difficult to perform because they require intraesophageal positioning of the catheter or probe. Fortunately, the incidence of motility disorders is rare in this population, and there is no need to prove esophageal acid exposure before operating on the patient.
♦ Pulmonary function tests should be performed in patients with a history of shortness of breath or impaired exercise tolerance. Significant improvement in restrictive lung disease can be expected after surgery.
Equipment and instrumentation
♦ The procedure is performed through five ports: three 5-mm ports and two 10-mm ports. The left upper quadrant 10-mm port can be upsized to accommodate a roticulating endoscopic stapler if an esophageal lengthening procedure is to be performed.
♦ A 30-degree 10-mm laparoscope is used.
♦ A ¼-inch 4-cm long Penrose drain secured with a chromic Endoloop is useful for retracting the upper stomach.
♦ Advanced laparoscopic instruments are needed, including atraumatic bowel graspers such as Hunter graspers (Jarit), laparoscopic Metzenbaum scissors, and needle drivers.
♦ The hook electrocautery is fast and can be used for much of the dissection of the crura. The laparoscopic 5-mm curved harmonic scalpel (ultrasonic coagulator) is used for division of the short gastric vessels and mediastinal dissection.
Anesthesia
♦ Patients with severe carbon dioxide retention, noted during the preoperative workup, can be difficult to manage intraoperatively. The anesthesiologist can reduce CO2 retention by increasing minute ventilation, and the surgeon can decrease the level of CO2 absorption by decreasing the pneumoperitoneum. An alternative insufflating agent such as nitrous oxide can be used.
♦ Following induction of general anesthesia, an orogastric tube and Foley catheter are placed. If there is difficulty passing the orogastric tube, it should not be forced, but it should be attempted again after the contents of the sac have been reduced.
Room setup and patient positioning
♦ The patient is placed supine on a split leg table with arms out and the legs abducted in a 45-degree angle at the hip. Footplates are used to prevent sliding when the patient is placed in reverse Trendelenburg position.
♦ The surgeon stands between the patient’s legs to allow for the best access to the hiatus. The assistant stands on the patient’s left side. Monitors are placed at the head of the table.
