Novel Combined Vats/laparoscopic Approach for Giant and Complicated Paraesophageal Hernia Repair: Description of Technique and Early Results

Daniela Molena, MD, Benedetto Mungo, MD, Miloslawa Stem, MS, Anne O Lidor, MD, MPH. Johns Hopkins Medicine.

Objective of the study/technique: The laparoscopic approach for repair of giant and/or recurrent paraesophageal hernias (PEH) is challenging, due to limited access to the dissection of the hernia sac into the proximal mediastinum and to esophageal mobilization through the diaphragmatic hiatus.
Often an esophageal lengthening procedure is necessary, due to the difficulty in obtaining adequate intra-abdominal esophageal length.
We therefore developed a VATS and laparoscopic technique, which combines the benefits of minimally invasive surgery to a safer and more extensive thoracic dissection, and to optimal fundoplication, cruroplasty and gastropexy.

Description of the methods: After lung isolation the procedure starts with a standard left VATS approach. We use 4 laparoscopic trocars and the chest is inflated with CO2 at 8 mmHg. The visualization of the hernia sac is optimal. The inferior pulmonary ligament is divided and the lung retracted anteriorly. The hernia sac is dissected posteriorly from the thoracic aorta, inferiorly from its diaphragmatic attachments and anteriorly from the pericardium. The esophagus is identified at the superior edge of the hernia sac, and it is completely mobilized up to the aortic arch. The anterior vagus nerve is released from its bronchial branches. The hernia sac is then opened, dissected and completely removed. The patient is subsequently positioned supine for the abdominal portion of the procedure. After reduction of the hernia content into the abdomen, the short gastric vessels are divided and the gastric fundus is completely mobilized. The hiatus is closed with interrupted sutures, and the cruroplasty is buttressed with a biological mesh. A floppy Nissen fundoplication and a gastropexy are done for reflux control and gastric fixation.

Preliminary results: From January 2012 to September 2013 we treated 14 patients with the above described procedure. 5 patients (35.7%) had type III PEH and 9 (64.3%) type IV PEH. 5 patients (35.7%) had previous history of antireflux surgery. We performed planned laparotomy instead of laparoscopy in 2 (14.3%) patients, who needed concurrent repair of complex incisional hernias. We didn’t need esophageal lengthening procedures, nor experienced damages to thoracic structures in any patient.

Conclusions/Expectations: Our newly developed surgical approach has proven to be safe and feasible. This technique represents a good option for treatment of giant and complicated PEH.

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