Operation for Paraesophageal Hernia

Jean-Marie Michel, Lukas Krähenbühl


Postempski first reported the repair of a wound of the diaphragm in 1889. Ackerlund described different types of paraesophageal hernia in 1926, and the first hiatal hernia repair (fundoplication) was reported by Nissen in 1955. Since then, Nissen fundoplica-tion has gained wide acceptance and is now recognized as the operation of choice for antireflux surgery and, although technically challenging, laparoscopic paraesophageal hernia repair.

The goal of a paraesophageal hernia repair is to bring the stomach (with other organs such as colon, omentum, spleen) and the lower esophagus back into the abdominal cavity, to excise the hernia sac, to approximate crura, to perform a fundoplication in order to prevent gastroesophageal reflux, and finally to perform a gastropexy in order to prevent gastric volvulus.

Indications and Contraindications: Laparoscopy

Indications ■ Symptomatic or asymptomatic Type II and Type III hiatal hernia

Contraindications Absolute Contraindications

■ Gastric incarceration

■ Intrathoracic gastric perforation with Type II or Type III hiatal hernia

Relative Contraindications

■ Partially fixed paraesophageal hernia

■ Short esophagus

Indications and Contraindications: Laparotomy

Indications ■ As for laparoscopy

■ Gastric incarceration

Contraindications Absolute Contraindications

■ Intrathoracic gastric perforation with Type II or Type III hiatal hernia

Relative Contraindications

Preoperative Preparation/Preparation for the Procedure

History: Long-term history of gastroesophageal reflux disease (GERD), symptoms of upper GI occlusion Upright radiograph Search for a retrocardiac air-fluid level of the thorax:

Contrast radiographic Preoperative localization of the gastroesophageal junction, studies (barium swallow): assessment of the type of hernia Esophageal manometry: To exclude a motility disorder of the esophagus Upper endoscopy: Objective GERD and/or exclusion of gastric ulcer disease

24-h pH monitoring and (Facultative) look for GERD and esophageal dysmotility. stationary manometry: In type II hernias, 70 % of patients have pathologic pH-metry, with up to 100% of patients with type III hernias.

Actively treat dehydration

Empty the stomach: Nasogastric tube or immediate preoperative endoscopy Single-shot antibiotic with second generation cephalosporine


The patient is placed in a modified lithotomy position. The table is placed in a steep reverse Trendelenburg position (French position), with the surgeon standing between the patient's legs, the first assistant on the patient's left, and the camera assistant on the patient's right.

Port Placement

A 10-mm port is placed 5-8cm above the umbilicus in the midline (open Hasson technique).A carbon dioxide pneumoperitoneum is established (12mmHg).A 30°-angle laparoscope is mandatory. After exploratory laparoscopy, the next four trocar sleeves are placed under direct vision. A subxiphoid 5-mm port for liver retraction, two working ports: one 5-mm one in the right upper quadrant (UQ), another 10-mm one in the left UQ, and a 5-mm left subcostal port.

Hiatal Hernia Left Upper Quadrant


To allow free access to the enlarged esophageal hiatus, the left lobe of the liver has to be elevated with a liver retractor.

Herniated Stomach

STEP 1 Reduction of herniated stomach

The herniated stomach and the greater omentum are reduced into the abdominal cavity with two Babcock graspers. A nasogastric tube is then introduced to decompress the stomach.

This maneuver is a dangerous step of the procedure with risks of stomach perforation, particularly in case of mechanical obstruction of the stomach (volvulus) with incarceration and gastric wall ischemia.

The spleen, colon, and omentum can also be herniated into the thorax.

STEP 2 Exposure of the hiatal hernia

Open the gastrohepatic ligament after reduction of the hernia content, and expose the right crus of the diaphragm. The hepatic trunk of the vagus nerve and aberrant left hepatic artery should be preserved if possible. The hiatus and the hernia sac are now visible.

STEP 3 Circular incision of the hernia sac

Start the procedure on the right side and dissect the hernia sac off the right crural edge using the harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH, USA). Complete the dissection inferiorly and obtain a good exposure of the junction between the right and left crura, then cranially with the incision of the phrenoesophageal membrane, finally to the left over the left crus. The dissection over the inferoposterior edge of the left crus is difficult at this moment and is best achieved when the hernia sac is completely reduced from the mediastinum.

Disection Paraoesophageal Sac

STEP 4 Blunt dissection of the hernia sac

The hernia sac now should be bluntly removed from the mediastinum with complete exposure of the right and left crura (see STEP 3).

During this step anterior and posterior vagal nerves have to be identified and protected; this could be difficult to perform in inflammatory tissue.

It is not rare that the left and/or right pleura can be opened within the mediastinum during blunt dissection, but most of the time a pleural drainage is not mandatory.

Complete the dissection of the inferoposterior edge of the left crus. Pay particular attention to finding the good plane between the esophagus and the body of the left crus, which may sometimes be extraordinarily difficult. It is not necessary to excise the hernia sac.

STEP 5 Intra-abdominal reduction of the gastroesophageal junction (GEJ)

The distal esophagus is now completely freed and a Penrose drain has to be placed around the GEJ junction to permit a better retraction in the abdominal cavity. It is reported that as many as 15% of giant type III paraesophageal hernias will present with a shortened esophagus and have an irreducible GEJ. Adequate mobilization of the esophagus then should be performed as high as possible into the mediastinum. If the reduction remains impossible after this maneuver, the patient will most benefit from a Collis-Nissen gastroplasty, which has been reported to be feasible using a laparoscopic and/or thoracoscopic approach.

Hiatal Closure


Closure of the hiatal defect (posterior cruroplasty)

The hiatal defect is closed with five to six nonabsorbable 2-0 Ethibond mattress sutures placed posteriorly and anteriorly from the esophagus to return the GEJ into the abdomen. The sutures are placed from caudad to cephalad so the hiatus is snug around the esophagus:

The axis of the hiatal hernia has an inferosuperior direction with an angle of about 10% clockwise in the perpendicular plane, and an inferosuperior direction with an angle of about 70 % clockwise in the sagittal plane. Thus closure of the hiatal defect must follow the schema represented in A.

Hiatal Closure

Closure of the hiatal defect (posterior cruroplasty)

Sometimes one or two anterior sutures are mandatory to avoid an "S-shape" of the distal esophagus. The inferior edge of the newly created hiatus may produce an external compression leading to dysphagia (B).

Some groups use a prosthetic reinforcement with polytetrafluoroethylene (PTFE) of posterior cruroplasty to reduce the rate of postoperative wrap herniation into the mediastinum.

Posterior Cruroplasty

STEP 7 Nissen fundoplication

Perform a floppy 2-cm three-stitch Nissen fundoplication over a 56F bougie after mobilization of the great curvature (we divide the short gastric vessels). The most cephalad stitch of the fundoplication superficially incorporates the esophagus wall.

STEP 8 Anterior gastroplasty

Perform an anterior gastroplasty with two to three interrupted nonabsorbable 2-0 Ethibond sutures between the greater curvature and the anterior abdominal wall to prevent postoperative intra-abdominal gastric volvulus.

Postoperative Tests

■ Resume alimentation the day after surgery

■ Obtain a barium esophagogram within 1 month (for follow-up purposes)

Postoperative Complications

■ Pneumothorax

■ Pleural effusion

■ Vagus nerve injury (anterior and posterior bundles)

■ Cardiac dysrhythmia

■ Pericarditis

■ Pneumothorax

■ Pulmonary embolism

Tricks of the Senior Surgeon

■ Use nonabsorbable mattress sutures to perform the posterior cruroplasty.

■ At the end of the procedure, perform an anterior gastropexy to avoid postoperative gastric volvulus.

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