Laparoscopic Repair of Giant Type Iii Hiatal Hernia Without Mesh Reinforcement

Thiago Boechat, MD, Leonardo Ferraz, MD, Marcio Balieiro, MD, Baltazar Fernandes, MD, Jose Ribamar Azevedo, MD. Bonsucesso Federal Hospital.

 A giant hiatal hernia is a hernia that includes at least 30% of stomach inside the chest, its can be type II and III. The prevalence of giant hernia represent from 0,3% to 15% of all hiatal hernias. The pathophysiology isn’t entire clear and has two possibles mechanism: gastrooesophageal junction traction in decorrence of gastoesophageal reflux disease and chronic positive pressure over diaphragmatic hiatos combined with a propensity of stomach herniation inside the chest. A strong correlation between hiatal hérnia and gastroesophageal reflux disease exist and its the basis for the performance of an antireflux procedure. Because the potential risk of incarceration, strangulation or gastric volvulus, all patiants with type II or III hérnia should be taken for surgical corretion, unless comorbities are prohibitive. The surgical treatment should attempt for three basic principles: 1) hernia complete reduction, sac resection and crural defect. repair; 2) assessment of intraabdominal esophageal length; and 3) antireflux procedure association. This type of hernia are usually associated with large diaphragmatic crural defect.(>4cm) and its closure technic is a matter of debate in the literature, because its synthesis fail rate can reach 40% in some studies. Some authors use synthetic or biological mesh to reinforce the crura and avoid or diminish the recurrence rate. But this prosthetics meshes can be origin of importants complications such as esophageal erosion. In this video we presente a case of 58y, caucasian, male patiant with heartburn and gastroesophageal reflux syntoms and in continuos use of próton pump inhibitors for the last 30 years. An upper endoscope was taken evidencing a giant hiatal hernia with a large crural defect. CT scan confirm the herniation and a diaphragmatic defect with at least 50% of the stomach inside the chest. The patient was submitted an elective laparoscopic surgical approach respecting the basics principles: hernia reduction, sac excision, crural repair, enought intra-abdominal esophageal length and an antireflux procedure. We did not use mesh in the crura and routinely do a floppy nissen fundoplication. The patient had a good pos operative evolution receving a liquid diet on first pos operative day and discharged on the second. In his follow up was made a barium esophagogram without evidencing recurrence.

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