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After transverse incision at upper pole of the umbilicus establish pneumoperitoneum and then insert 10 mm laparoscope. Insert four 5 mm trocars under transillumination in a semicircle superior to the umbilicus, one each in the left and right medioclavicular and anterior axillary line. Work through both medial 5 mm trocars, while the left lateral trocar is used for the liver retractor and the right lateral trocar for a grasper holding the stomach. Anti-Trendelenburg position of the patient and OR Table tilted slightly to the left.
Incising the greater omentum and exposing the right crus of the diaphragm
Lifting up the left hepatic lobe with a liver retractor reveals the esophageal hiatus. Dissection with the harmonic scalpel begins by incising the lesser omentum at the pars flaccida while simultaneously pulling the stomach up to the left to the free margin of the right crus of the diaphragm. Now expose the gastroesophageal junction at the right crus while evading the posterior vagal trunk.
Exposing the left crus of the diaphragm
Mediastinal mobilization of the distal esophagus
Now dissect the distal esophagus in the mediastinum, with the harmonic scalpel and also bluntly, so that it is exposed circucumferentially over a distance of at least 10 cm; in the end 4 cm - 5 cm of the esophagus should rest tension-free in the peritoneal cavity. Dissection is markedly facilitated by encircling the esophagus and the posterior vagal trunk with a tape.
In order to prevent the subsequent hiatoplasty from constricting the terminal esophagus, insert a 40F gastric tube as bougie for calibration purposes. Adapt both crura of the diaphragm posterior to the esophagus by interrupted sutures whose knots are tied extracorporeally and then guided into proper position with a knot pusher (hangman’s knot). Use non-absorbable sutures size 0. The video clip demonstrates the first of a total of three sutures.
- The sutures must include the peritoneal cover of the crura of the diaphragm which frequently pulls back to the side during dissection.
- In very large hiatal hernia and upside-down stomach with the risk of volvulus, the hiatus may be constricted further by additional sutures anterior to the esophagus.
Mesh augmentation of the esophageal hiatus
In large defects, particularly in para-esophageal hernias, mesh augmented hiatoplasty is recommended to prevent wrap dislocation into the mediastinum.
Here, a keyhole-like opening is cut into a 6 cm x 8 cm biomesh, which is placed around the esophagus like a collar. Fixate the mesh with absorbable tacks.
- Non-absorbable meshes may result in serious complications. Esophageal erosion, mesh migration into esophagus and stomach.
- Mesh fixation at the hiatus with spiral tacks is not exactly safe because injuries to the pericardium and coronary vessels have been reported. When in doubt about where to place the tacks, fixate the mesh with fibrin sealant.
Mobilizing the gastric fundus
After removing the encircling tape prepare for the fundoplication by mobilizing the entire gastric fundus along the greater curvature with division of the proximal gastrosplenic ligament. In oder to apply tension to the short gastric vessels, pull the stomach to the right with judicious use of force. Divide these vessels successively with the harmonic scalpel. Full mobilization of the proximal stomach requires that all posterior retroperitoneal adhesions with the fundus must be divided. The space created posteriorly must be large enough to accommodate the fundus pull-through later on.
For the 360° fundoplication pull the mobilized fundus posterior to the esophagus to the right with an atraumatic grasper. The inserted gastric tube calibrates the wrap and prevents esophageal constriction while performing the actual plication. Construct a short floppy Nissen fundoplication with the anterior and posterior wall of the gastric fundus. Fixation comprises 2 interrupted seromuscular sutures whose knots are tied extracorporeally and guided into proper position with a knot pusher, just as in the hiatoplasty. This step, too, relies on non-absorbable sutures size 0 (here: Ethibond®).
- The shoeshine maneuver can facilitate wrap positioning: In order to verify the correct position and length of the mobilized fundus, loosely pull the fundus back and forth posterior to the esophagus, just as you would when polishing shoes.
- The vagal trunk will remain within the wrap.
- The proximal wrap suture takes a seromuscular bite trough the anterior cardiac wall. It therefore defines the length of the intraabdominal segment of the esophagus and prevents wrap slippage.
- As demonstrated in the video clip, the bite into the anterior cardiac wall should be on the right of the cardia and not on its anterior aspect because this is where the anterior vagal nerve usually courses.
- The wrap is floppy enough if, after removal of the gastric tube, a 5 mm grasper can slip easily between the esophagus and wrap.
Leak testing, drainage