Overview
Definition:
Laparoscopic hiatal hernia repair is a minimally invasive surgical procedure to correct a hiatal hernia, where a portion of the stomach protrudes through the diaphragm into the chest cavity
The primary goals are to reduce the hernia sac, close the diaphragmatic crura, and reconstruct the gastroesophageal junction, often with an anti-reflux procedure (fundoplication).
Epidemiology:
Hiatal hernias are common, particularly in older adults and individuals with obesity
Symptomatic hiatal hernias requiring surgical intervention occur less frequently, with prevalence increasing with age
Obesity and pregnancy are significant risk factors.
Clinical Significance:
Untreated symptomatic hiatal hernias can lead to chronic gastroesophageal reflux disease (GERD), esophagitis, strictures, Barrett's esophagus, and even aspiration pneumonia
Laparoscopic repair offers a definitive treatment option with reduced morbidity compared to open surgery, making it a crucial skill for surgical residents.
Indications
Absolute Indications:
Large paraesophageal hernias at risk of strangulation or incarceration
Symptomatic hernias refractory to maximal medical management.
Relative Indications:
Recurrent esophagitis despite medical therapy
Severe heartburn, regurgitation, or dysphagia not controlled by medication
Patient preference for surgical intervention
Barrett's esophagus in conjunction with GERD symptoms.
Contraindications:
Severe comorbidities precluding general anesthesia or prolonged pneumoperitoneum
Uncontrolled coagulopathy
Active peptic ulcer disease or severe erosive esophagitis that can be managed medically first
Patient refusal or inability to comply with postoperative care.
Preoperative Preparation
Patient Evaluation:
Thorough history and physical examination focusing on reflux symptoms, dysphagia, and cardiopulmonary status
Assessment of comorbidities like obesity, diabetes, and cardiovascular disease.
Diagnostic Workup:
Upper gastrointestinal endoscopy to assess the grade of hernia and rule out malignancy or complications like strictures/Barrett's
Barium swallow for anatomical detail and assessment of hernia type and size
Esophageal manometry and 24-hour pH monitoring may be considered in complex cases or if reflux is atypical.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is required
Careful insufflation of the abdomen to create a working pneumoperitoneum, monitoring for hemodynamic instability
Postoperative pain management strategies.
Procedure Steps
Port Placement:
Typically 4-5 ports are used: one 10-12 mm umbilical port for the camera and 10 mm ports in the epigastrium and left subcostal region for instruments
Additional working ports may be placed in the left mid-clavicular line.
Mobilization And Reduction:
The gastroesophageal junction is identified
The short gastric vessels are divided to mobilize the gastric fundus
The hiatal crura are dissected free from the esophagus and vagal nerves
The stomach is reduced back into the abdominal cavity.
Crural Closure:
The diaphragmatic crura are approximated using non-absorbable sutures (e.g., Ethibond) to narrow the hiatus, typically to allow only the esophagus to pass without tension
The goal is a hiatus size of approximately 2-3 cm.
Fundoplication:
A partial (Toupet) or complete (Nissen) fundoplication is performed
For a Toupet fundoplication, the posterior aspect of the gastric fundus is wrapped around the esophagus 180-270 degrees
For a Nissen fundoplication, a 360-degree wrap is performed
The wrap is secured to the esophagus and crura to prevent slippage.
Postoperative Care
Immediate Postoperative:
Patients are typically admitted for observation
Pain management is crucial
Patients are started on a clear liquid diet and advanced as tolerated
Proton pump inhibitors (PPIs) are usually continued.
Dietary Advancement:
A progressive diet starting with liquids, followed by pureed, soft, and then regular food over several weeks to allow for healing and adaptation
Patients are instructed to eat slowly, chew thoroughly, and avoid large meals.
Activity And Followup:
Gradual return to normal activities
Strenuous exercise should be avoided for 4-6 weeks
Routine follow-up appointments are scheduled to assess symptom resolution and monitor for complications
Endoscopy may be performed at 6-12 months postoperatively.
Complications
Early Complications:
Bleeding from dissection sites or staple lines
Gastric perforation
Esophageal injury
Pneumothorax or hemothorax
Postoperative pneumonia
Anesthesia-related complications
Transient dysphagia or gas bloat syndrome.
Late Complications:
Recurrence of hiatal hernia
Persistent dysphagia or odynophagia
Incisional hernia at port sites
Diaphragmatic dysfunction
Dumping syndrome (less common with partial fundoplication).
Prevention Strategies:
Meticulous surgical technique with careful dissection
Adequate crural closure without excessive tension
Appropriate selection of fundoplication type
Effective postoperative pain control and early mobilization
Patient education on diet and activity.
Key Points
Exam Focus:
Understand the different types of hiatal hernias (Type I, II, III, IV)
Differentiate between Nissen and Toupet fundoplication indications and outcomes
Recognize complications of laparoscopic repair and their management
Know the critical steps of hiatal dissection and crural closure.
Clinical Pearls:
Always confirm the gastroesophageal junction location before division of short gastric vessels
Adequate mobilization of the gastric fundus is essential for a tension-free wrap
Secure sutures for crural closure to prevent recurrence
Monitor for signs of bowel obstruction postoperatively.
Common Mistakes:
Incomplete division of short gastric vessels leading to difficult mobilization
Inadequate crural dissection or over-tightening of sutures causing excessive tension and dysphagia
Performing a fundoplication in a patient with significant preoperative dysphagia or motility disorder
Failure to recognize recurrence symptoms.