Overview

Definition:
-Esophageal hiatus closure, primarily through cruroplasty, refers to the surgical techniques employed to narrow the diaphragmatic opening (esophageal hiatus) through which the esophagus passes into the abdomen
-This procedure is most commonly performed as part of anti-reflux surgery for large paraesophageal hernias or severe gastroesophageal reflux disease (GERD)
-Cruroplasty aims to restore the crural integrity and prevent herniation of abdominal contents into the thoracic cavity.
Epidemiology:
-Hiatal hernias, particularly sliding hiatal hernias, are highly prevalent, affecting up to 50% of the population
-Large paraesophageal hernias, which are more frequently symptomatic and require surgical intervention, are less common but are a significant indication for hiatus closure
-The incidence of symptomatic large paraesophageal hernias requiring surgery is estimated to be around 1-5 per 100,000 population annually.
Clinical Significance:
-Inadequate closure of the esophageal hiatus can lead to recurrence of hiatal hernia, persistent or worsening GERD symptoms, and potentially life-threatening complications such as gastric volvulus or strangulation, especially in paraesophageal hernias
-The choice of cruroplasty technique significantly impacts the recurrence rates and the risk of complications, making it a crucial consideration for surgical trainees preparing for DNB and NEET SS examinations.

Indications For Surgery

Symptomatic Paraesophageal Hernia: Large paraesophageal hernias that cause dysphagia, chest pain, shortness of breath, or significant reflux symptoms.
Large Sliding Hiatal Hernia With Gerd: Large sliding hiatal hernias refractory to medical management, causing severe reflux symptoms, or associated with complications like stricture or Barrett's esophagus.
Strangulation Or Obstruction: Acute presentation of a hiatal hernia with signs of incarceration, strangulation, or obstruction, requiring emergent surgical repair.
Failure Of Medical Management: Persistent GERD symptoms despite optimal medical therapy, particularly when associated with anatomical abnormalities of the hiatus.

Surgical Approaches And Techniques

Approach Selection:
-The surgical approach can be either transthoracic (thoracoscopic or open thoracotomy) or transabdominal (laparoscopic or open laparotomy)
-Laparoscopic approach is now the gold standard for elective repair due to faster recovery and reduced morbidity.
Posterior Cruroplasty:
-This is the most common technique
-It involves bringing the diaphragmatic crura together posterior to the esophagus using sutures
-It aims to narrow the hiatus to a finger-breadth (approximately 1-2 cm) to prevent herniation
-It can be combined with fundoplication (e.g., Nissen or Toupet) to enhance anti-reflux function.
Anterior Cruroplasty:
-Less commonly used, this technique involves approximating the crura anterior to the esophagus
-It is sometimes employed in specific situations, such as after previous posterior repairs or when extensive scarring makes posterior dissection difficult
-Its efficacy and long-term outcomes compared to posterior cruroplasty are debated.
Mesh Reinforcement:
-In cases of large hiatus defects or recurrent hernias, prosthetic mesh (e.g., GORE-TEX, Parietex) may be used for reinforcement to reduce the risk of recurrence
-However, its use is associated with potential complications like mesh erosion or infection, and its routine use is still debated.
Hiatus Closure Principles:
-Regardless of the technique, the goal is to create a snug fit around the esophagus, typically allowing passage of 1-2 fingers, without causing esophageal obstruction or impairing peristalsis
-Excessive tension on the sutures should be avoided.

Preoperative Evaluation And Preparation

History And Physical Examination:
-Detailed history focusing on reflux symptoms (heartburn, regurgitation), dysphagia, chest pain, and respiratory symptoms
-Physical examination to assess nutritional status and identify any abdominal wall hernias.
Diagnostic Investigations:
-Upper GI endoscopy is essential to assess for esophagitis, Barrett's esophagus, strictures, and to confirm the hernia
-Barium swallow can delineate the anatomy of the hernia and assess for gastric volvulus
-Esophageal manometry and 24-hour pH monitoring may be indicated in complex cases or if reoperation is considered.
Anesthesia Considerations:
-General anesthesia with endotracheal intubation is typically used
-Careful anesthetic management is required, especially for thoracoscopic approaches, to optimize ventilation and hemodynamics.
Bowel Preparation:
-Standard bowel preparation for abdominal surgery is performed
-Patients are usually advised to be nil by mouth from midnight prior to surgery.

Postoperative Care And Management

Pain Management:
-Adequate analgesia is crucial, often involving patient-controlled analgesia (PCA) or epidural anesthesia, followed by oral pain medications
-Multimodal pain strategies are recommended.
Dietary Advancements:
-Diet is typically advanced from clear liquids to soft foods as tolerated, avoiding spicy, acidic, or gas-forming foods for the initial weeks
-Patients are advised to eat small, frequent meals.
Mobility And Activity:
-Early ambulation is encouraged to prevent deep vein thrombosis and pulmonary complications
-Strenuous activity and heavy lifting should be avoided for 4-6 weeks post-surgery.
Monitoring For Complications:
-Close monitoring for signs of bleeding, infection, anastomotic leak (if intragastric portion is manipulated), dysphagia, and respiratory compromise is essential
-Chest X-ray may be performed postoperatively.

Complications Of Esophageal Hiatus Closure

Early Complications: Bleeding, infection (wound or intrathoracic), pneumothorax, injury to adjacent organs (spleen, vagus nerve), phrenic nerve injury, staple line or suture dehiscence, acute gastric distension, or obstruction.
Late Complications: Recurrence of hiatal hernia, dysphagia, slipped fundoplication, gas-bloat syndrome, chronic pain, mesh-related complications (if used), recurrent GERD, staple line granuloma, or esophageal stricture.
Prevention And Management:
-Meticulous surgical technique, appropriate suture placement to avoid tension, adequate patient selection, and careful postoperative care are key to prevention
-Management of complications depends on their nature and severity, ranging from conservative measures to reoperation.

Key Points

Exam Focus:
-Understand the indications for hiatus closure, the fundamental differences between posterior and anterior cruroplasty, and their respective advantages and disadvantages
-Know the common complications and their management
-Focus on the principles of creating a snug, non-obstructive repair.
Clinical Pearls:
-Achieving adequate approximation of the crura without excessive tension is paramount to prevent dysphagia and recurrence
-Intraoperative assessment with a bougie or finger is often used to gauge hiatus size
-Laparoscopic repair offers significant benefits in recovery.
Common Mistakes: Overly tight repair leading to dysphagia, too loose a repair leading to recurrence, ignoring potential injury to adjacent structures like the spleen or vagus nerves, and failing to adequately address the anti-reflux mechanism when indicated.