Laparoscopic Paraesophageal Hernia Repair
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Procedure Outline
Table of Contents
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- Pneumoperitoneum achieved via a Veress needle and subsequent placement of a supraumbilical camera port under direct visualization.
- Place Left Side Instrument Trocar
- Retract Left Lateral Segment of Liver
- Place Second/Third Trocars Completing Triangle
- Dissect Gastrohepatic Ligament
- Must always be aware of the potential for an accessory or replaced left hepatic artery within the gastrohepatic ligament.
- Dissect Hernia Sac off Left Crus
- Dissect Hernia Sac off Right Crus
- Dissect Posterior Aspect of Hernia Sac
- Identify Posterior Vagus Nerve
- Transect Short Gastric Arteries
- Dissect Hernia Sac from Greater Curvature of Stomach
- Expose Esophagus Cephalad to Sac and Identify Anterior Vagus Nerve
- Dissect the Stomach off the Inner Layer of the Hernia Sac
- Excision of Hernia Sac
- Continue Hernia Sac Dissection of Stomach
- Dissect Lesser Curvature of Stomach
- Further Mobilization of the Esophagus
- Dissect Mediastinal Pleura Tissue from Spine/Aorta
- Place Vessel Blue Loops around GE Junction
- Use the Endoloop to encircle the blue vessel loop to provide retraction of the GE junction of the stomach.
- Continue Dissection of Posterior Hernia Sac from Stomach
- Dissect Lower End of Left Crus
- Combined Extra- and Intracorporeal Knotting Technique
- Closure of the crus is done posterior to the esophagus utilizing a 0-Ethibond pledgeted suture on a straight needle.
- In an extracorporeal fashion, a half-stitch is thrown 6 times to form an “extra tight slip knot”.
- An intracorporeal knot is used to complete the square knot during crural closure.
- Ensure Esophagus Dissected and Lengthened
- Closure of hiatus in the manner shown (3 cm in abdomen) increases the length of intra-abdominal esophagus by transposing the hiatal orifice cephalad
- Align Short Gastric Arteries
- Align the short gastric arteries along the top of the fundoplication.
- Fundoplication performed with a 5.5-inch silk stitch.
- Posterior Gastropexy
