Paraesophageal Hernia Repair Flashcards
(30 cards)
What is the most common acquired diaphragmatic hernia?
Hiatal hernia.
What structural changes are associated with a hiatal hernia?
Widening of the esophageal hiatus and weakening of the phrenoesophageal ligament.
What symptoms suggest the presence of a larger paraesophageal hernia?
Abdominal pain after eating, anemia, and partial organo-axial volvulus of the stomach.
What type of hiatal hernia is the most common?
Type I hiatal hernia, accounting for 90% to 95% of all hernias.
Presents with GERD
What are the additional symptoms often seen with type II, III, and IV paraesophageal hernias?
Early satiety
anemia
postprandial abdominal or chest pain
vomiting, dysphagia, and weight loss
What is the defining characteristic of a Type I paraesophageal hernia?
The esophagogastric junction (EGJ) herniates above the diaphragm into the mediastinum
“sliding hernia.”
How is a Type II paraesophageal hernia classified?
A portion of the stomach herniates into the mediastinum alongside a normally positioned (intraabdominal) EGJ.
What is the defining feature of a Type III paraesophageal hernia?
The EGJ is above the hiatus, and a portion of the stomach is folded alongside the esophagus.
What distinguishes a Type IV paraesophageal hernia from other types?
An intraabdominal organ other than the stomach also herniates through the hiatus.
What factors determine the indication for surgery in patients with a paraesophageal hernia?
The severity of the patient’s symptoms and their other comorbid medical conditions.
When might patients with a paraesophageal hernia be managed without surgery?
When their symptoms are well controlled on acid suppression medications, and they do not have dysphagia, weight loss, or pain.
What imaging studies are commonly used to evaluate paraesophageal hernias?
Contrast esophagram and computed tomography (CT) scan.
Why is upper endoscopy important in the evaluation of paraesophageal hernia patients?
To determine the presence of esophagitis, gastritis, Cameron ulcers, peptic ulcer disease, and to rule out malignancy
What role does esophageal manometry play in the management of type I and type II paraesophageal hernias?
It assesses esophageal motility to guide the decision for the appropriate fundoplication during hernia repair.
Why is esophageal manometry difficult to perform in patients with large type III or type IV paraesophageal hernias?
The catheters often curl in the esophagus or herniated stomach, limiting the accuracy of the data.
So you Do Partial Fundo for them
In which patients is pH testing critically important
In patients with significant symptoms of gastroesophageal reflux disease (GERD) without the presence of a paraesophageal hernia.
Which types of paraesophageal hernias are almost always successfully repaired using the laparoscopic technique?
Type I and type II paraesophageal hernias.
What are the advantages of laparoscopic repair of type I and II paraesophageal hernias?
It is associated with decreased operative morbidity compared to thoracotomy
What complications may arise during the laparoscopic repair of large type III and IV paraesophageal hernias?
Pneumothorax and loss of pneumoperitoneum due to adhesions between the hernia sac and structures like the pericardium, lung, and airway.
Why might open repair be preferred for large paraesophageal hernias?
Open repair provides better visualization, especially for structures above the level of the inferior pulmonary veins.
What are some relative indications for open repair rather than laparoscopic repair of paraesophageal hernias
Previous paraesophageal hernia repair
extension into pleural spaces
and proximal extension to the level of the carina.
Laparoscopic Repair of Paraesophageal Hernias (Hernia Sac)
-NGT Decompress Stomach
-Supine Position
-5 Ports ( Camera,2 for Surgeon,1 Assistant,1 Liver)
-Camera Medline 14 cm Below Xiphoid
-Open Gastrohepatic Ligament
-Attention to a replaced or accessory left hepatic artery.
-periesophageal tissues are then dissected
-anterior and posterior vagus nerves are identified.
-dissect the sac away from the pericardium
-hernia sac is then dissected away from the left crus
-expose the posterior aspect of right and left crura
-The posterior dissection is completed allowing the herniated stomach and the hernia sac to be reduced into the abdomen
-mobilize the greater curvature of the stomach, dividing all short gastric vessels
-removing the entire hernia sac often results in small tears in the pleura, creating capnothorax with associated hypotension or increased airway pressure
Laparoscopic Repair of Paraesophageal Hernias (Mobilize Esophagus)
-mediastinal dissection is extended proximally by dividing the small esophageal arterial branches
-Dissection is continued up into the mediastinum to achieve at least 3 cm of intraabdominal esophagus
-It is quite helpful to decrease the insufflation from 15 mm Hg to 8 mm Hg
-Interrupted 0 Ethibond sutures reapproximate the posterior right and left crura just above the aorta
-both the aorta and inferior vena cava are in close proximity to the posterior crura.
-Before the last crural sutures are tied, a 52F or 56F bougie is carefully inserted down the esophagus, and there should be room for a closed grasper to easily slide between the esophagus and crura.
the use of biologic mesh for reinforcement of the crural closure ?
long-term recurrence rates are similar between cruroplasty alone versus cruroplasty with biologic mesh.
However, the overall morbidity seems to be higher in patients repaired with nonabsorbable mesh.
