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Hiatal Hernia Repair with Mesh and Toupet Fundoplication

Matthew E Sharbaugh, DO1, Kristin Mccoy, MD2, Tejinder P Singh, MD1. 1Albany Medical Center, 2Stamford Health

Optimal hiatal hernia repair technique has yet to be standardized.  There is still no consensus on the multiple technical aspects of the procedure including: mesh fixation, division of short gastric vessels, size of wrap, use of gastropexy and many more. The aim of our study was to evaluate the use of the robotic platform for hiatal hernia repair and demonstrate our standardized repair.  

Our patient was a 75-year-old female who was suffering from dysphagia and gastroesophageal reflux which had caused her to undergo a significant weight loss.  Her workup included a manometry study which showed normal contractility in the esophagus, an EGD which showed a large hiatal hernia with the GE junction located above the hiatus, and a upper GI series which demonstrated a 15 cm by 8 cm type 4 hiatal hernia.

The patient is positioned in reverse trendelenburg.  The first step consists of the dissection of the greater curvature of the stomach using ultrasonic shears to transect the short gastric vessels.  Next the gastric fundus is fully mobilized.  We continue this dissection until the left crus of the diaphragm is visualized.  The dissection is then carried across the anterior hiatus from left to right where we then enter the pars flaccida and identify the right crus.  The dissection continues until the two planes are joined.  Next the esophagus is mobilized from the posterior mediastinum to ensure adequate length in the abdomen and then encircled with an umbilical tape.

The hiatus is closed with figure of eight sutures.  It is important to reapproximate the crura by lifting the esophagus and including the superior portion of the left crura as this is the most common site of recurrence.  Next a mesh is anchored to the left and right crus of the diaphragm.  The previously mobilized fundus is brought posterior to the esophagus and a 300 degree toupet fundoplication is created. The fundus is anchored to both crura and to the mesh which we believe is an important step in reducing recurrences.  The fundoplication is created in a “V” like fashion to recreate the valve mechanism of the GE junction.  The final product is a 300 degree wrap with 3 cm length of the fundoplication anchored in the abdomen.  As the final step an endoscopy is performed to ensure proper passage through the gastroesophageal junction. The endoscope is retroflexed to evaluate for proper fundoplication effect.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 92209

Program Number: V332

Presentation Session: Video Loop Day 3

Presentation Type: VideoLoop

1,952

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