hiatal herniashiatal hernias · hiatal herniashiatal hernias ... h l h t i ll i bdominal pressure...

Hiatal HerniasHiatal Hernias

Kiyanda Baldwin, MD

SUNY Downstate Medical CenterSUNY Downstate Medical Center

August 27, 2009

www.downstatesurgery.org

Case PresentationCase Presentation29 y/o male truck driver with intractable 29 y/o male truck driver with intractable hiccups since 8/2008

PMH: GERD

PSH: lap chole 2003

Meds: thorazine

All: NKDA


Case PresentationCase PresentationPhysical Exam:

Afebrile, hemodynamically normal, Ht: 5’, Wt: 86kg

Within normal limits includingWithin normal limits includingBreath sounds clear to auscultationCVS S1S2, no R/M/GAbd soft, no organomegaly, scars from lap chole

Labs: unremarkableLabs: unremarkable


Case PresentationCase PresentationCXR 8/08:CXR 8/08:

WNL

EGD 2/09: 1cm hiatal hernia1cm hiatal hernia

Esophageal Manometry 3/09: Esophageal Manometry 3/09: hypotensive LES with good relaxationlow amplitude peristaltic contractionsp p


Case PresentationCase PresentationCT abd/pelvis 5/09CT abd/pelvis 5/09


Case PresentationCase Presentation

Barium Swallow 6/09:

D l i h l Delay in esophageal motility, GERD, hiatal herniahiatal hernia


Case PresentationCase Presentation6/26/09: laparoscopic converted to open Nissen f d li ti & t t h tfundoplication & emergent tracheostomy

POD #1: trach collar

POD #3: trach downsized

POD #4: trach capped

POD #5 b i ll l ll i POD #5: barium swallow: normal swallowing, normal motility, no delay, no reflux, no leak

Tolerated regular diet

POD #6: pt decannulated & discharged home


Case PresentationCase Presentation

Postoperative barium swallow on POD #5


Q i ? ?Questions ? ?


HistoryHistoryHenry Ingersoll Bowditch

1846 hiatal hernias described at postmortem

Technically first description of paraesophageal hernia.

1898 Walter Cannon & Albert Moser: 1898 Walter Cannon & Albert Moser: anatomy & physiology of the cardia w/ contrast material

1904 Eppinger: hiatal hernia diagnosed in live pt Stylopoulos N, Rattner DW. The history of hiatal hernia surgery: from Bowditch

to laparoscopy. Ann Surg. 2005 Jan; 241(1):185-93


HistoryHistory1955: Rudolph Nissen 1955: Rudolph Nissen Nissen Fundoplication

1957: J. Leigh Collis gastroplastyg p y

1970’s Nissen 1970 s Nissen fundoplication widely acceptedaccepted

Stylopoulos N, Rattner DW. The history of hiatal herniasurgery: from Bowditch to laparoscopy. Ann Surg. 2005Jan; 241(1):185-93


Hiatal HerniasHiatal Hernias

Type I: sliding

Type II: paraesophageal (“rolling”)

Type III: combined I & II

classified according to the anatomic position of the GEJ in relationship to the diaphragmatic hiatus the composition of relationship to the diaphragmatic hiatus, the composition of the hernia sac, and the extent of herniated stomach


Type IType IIntrathoracic GEJ, Contains gastric cardia and fundusContains gastric cardia and fundusNo true hernia sac

Most common of the 3 hiatal hernias

More common in women (4:1), 5th

& 6th decades, obese

Usually reducible but may become fixed above diaphragm

Attenuation of phrenoesophageal membrane (i e the subdiaphragmatic Attenuation of phrenoesophageal membrane (i.e., the subdiaphragmatic continuation of the transversalis fascia)

the phrenoesophageal membrane streches cranially due to intra-bd i l d th t f h l h t i ll i abdominal pressure and the tug of esophageal shortening on swallowing

Suggests acquired weakness of tissue secondary to aging and strain on diaphragm


Type IIType IIGEJ in normal GEJ in normal intraabdominal position

Fundus migrates superiorly along side the GEJ & esophagus into the mediastinum

True hernia

Giant: entire stomach in thorax


SymptomsSymptomsType I:yp

HeartburnRegurgitation(loss of antireflux mechanism; goal is to restore physiology of ( ; g p y gycardia)

Type II: Type II: Epigastric painPostprandial fullnessDysphagiaDysphagiaAbdominal bloatingRespiratory symptomsAnemia (1/3 of pts)Anemia (1/3 of pts)Borchardt’s triad: chest pain, retching w/ inability to vomit, inability to pass NGT


Work UpWork UpPhysical Exam

CXR

EGDSee pathology

Barium swallowEvaluate dysphagia short esophagus guide endoscopistEvaluate dysphagia, short esophagus, guide endoscopist

24 hr pH monitoring 60% paraesophageal, 71% sliding p p g , g

Manometry Esophageal motility, LES function, LES position

CTHelps confirm extent of hernia


Indications for SurgeryIndications for SurgeryFailure of medications to control symptoms

(however, pts with good response to medical Tx often (however, pts with good response to medical Tx often have better surgical response)

Complications while on medications (ulceration, Barrett’s, t i t )stricture)

Noncompliance with medical treatment

Preference for surgery over lifelong medications(cost, inconvenience, side effects)

Severely incompetent LES

Paraesophageal herniap g1. Isolauri J, Luostarinen M, Viljakka M, et al. Long-term comparison of antireflux surgery versus

conservative therapy for reflux esophagitis. Ann Surg. 1997;225:295–299. 2. DeMeester TR, Stein HJ. Surgical treatment of gastroesophageal reflux disease. In: Castell DO, ed. The

Esophagus. Boston: Little, Brown; 1992:579–626.


Goals of SurgeryGoals of SurgeryReturn herniated content below diaphragm

Resect hernia sac

Establish adequate esophageal length

Repair hernia defect


Laparoscopic Paraesophageal Hernia R iRepair

Positioning:Positioning:Low lithotomy, Steep trendelenbergp gHands tucked5 ports



Dissection:Dissection:Reduce hernia contentsDivide short gastricsgDissect sac off of L. crusIdentify esophagus & vagus

Use 52 Fr Bougie

Open hepatogastric ligamentDissect sac off of R crusDissect sac off of R. crusMediastinal dissection until 3cm intraabdominal esophagus w/o tensiongResect sac



Crural repairCrural repairClose crura post to esophagus

At decussation of R. & L. crura

Interrupted 2-0 nonabsorbable sutures

50 F b i ti ht t t 50 Fr bougie: assess tightness, prevent postop dysphagia



FundoplicationPull fundus through retroesophageal window

Mirror image of the ant & post fundusMirror image of the ant. & post. fundus

Ant & post fundus should meet at the 9 o’clock position

The divided vessels along the greater curvature should lie in apposition to the left crus

Sutured fundoplication should lie on the right side

3-4 sutures for 2.5-3cm fundoplication


Transhiatal Hernia RepairTranshiatal Hernia RepairEsophagoscopy: extent of path, confirm absence of malignancy

L. posterolateral thoracotomy (6th or 7th

intercostal space)

Resect 1cm segement of rib below


Transhiatal Hernia RepairTranshiatal Hernia RepairMobilization of Esophagus & excision of hernia sac

Divide pulmonary ligament to inf pulmonary V

Incise mediastinal pleura to expose esophagus from carina to diaphragm

Watch out for vagus nervesWatch out for vagus nerves

Encircle esophagus w/ vagus nerves w/ penrose drain

Elevate esophagus and mobilize circumferentially toward diaphragm

Separate sac from pericardium anteriorly & aorta posteriorly

Dissect left to right, ant to post


Transhiatal Hernia RepairTranshiatal Hernia RepairDivision of Phrenoesopheal Membrane & pGastrohepatic ligament

h l h h lRetract esophagus anteriorly to expose phrenoesophageal membrane posteriorly

Divide membrane to allow entry into lesser sac

Divide esophageal branch of L. phrenic artery near the crusDivide esophageal branch of L. phrenic artery near the crus

Divide gastrohepatic ligament along undersurface of the R. crus & down to L gastric Acrus & down to L. gastric A

Visualize caudate lobe of the liver beneath the R. crus


Transhiatal Hernia RepairTranshiatal Hernia RepairMobilization of the stomachMobilization of the stomach

Ligate short gastrics (3-4)Elevate GEJ into chest & release any yorganoaxial rotation

Closure of cruraPlace 3-5 stitches at 1cm intervals post to ant in staggered fashionin staggered fashionAvoid spleen on L. & aorta on R.


Transhiatal Hernia RepairTranshiatal Hernia RepairAssesment of Esophageal length & removal of ant fat pad

If t h d t d il h t If stomach does not reduce easily = short esophagus

Collis gastroplasty54 Fr bougie for women, 56 for men into stomach past GEJGEJBougie held anteriorly against lesser curvature, fundus retracted away at a R. angle to the esophagus60mm GIA applied immediately alongside the bougie on pp y g gthe greater curvatureOversew staple line w/ nonabsorbable 4-0 monofilament suture


Transhiatal Hernia RepairTranshiatal Hernia RepairFundoplication & reduction of wrap into abdomen

Fundus is passed posteriorly behind esophagus

Approximate fundus to esophagus or gastroplasty tube w/ 2 interrupted 2-0 silk sutures

Wrap should accommodate a finger alongside esophagusWrap should accommodate a finger alongside esophagus

2 clips placed at superior aspect of the wrap to confirm length & location of wrap on CXRg p

Remove bougie

Secure top of fundoplication to underside of diaphragm using 2 2-0 polypropylene mattress sutures


Types of FundoplicationTypes of FundoplicationNissen:

360 degrees360 degreesIncrease LES muscle pressurenormal esophageal length and normal motility

Toupet180 degreesNormal esophageal length and decreased motilityNormal esophageal length and decreased motility

Belsey Mark IV270 degrees through the chest270 degrees through the chest

Dor180 degree anterior wrap used w/ myotomy for achalasia180 degree anterior wrap used w/ myotomy for achalasia


Operative ManagementOperative ManagementOpen vs. Lap:

Minimal difference for experienced techniciansBenefits of Lap:

Improved visualization due to magnificationImproved visualization due to magnificationShorter hospital stay

Lap sometimes more difficult in obese pts

Indication for thoracic approachpplarger hernias w/ suspected esophageal shortening, allows maximal mobilization

i hi l h i i f di iPrior hiatal hernia repair, safer dissection

Current Surgical Therapy 9th Edition Cameron 2008


Operative ManagementOperative ManagementOutcomes:

Symptomatic: 88% have resolution for up to 4 yrs, 92% have resolution of anemia

Anatomic: 41% have recurrent hernia after 4 yrsAnatomic: 41% have recurrent hernia after 4 yrs

Long term success depends onLong term success depends on1. tension-free repair w/ 4cm intraabdominal esophagus 2. durable approximation of diaphragmatic crura3 t t hi f f d li ti t h i t th 3. correct matching of fundoplication technique to the peristaltic function of the esophagus

Current Surgical Therapy 9th Edition Cameron 2008


Ann Surg. 2006 July; 244(1): 42–51.

Repair of 104 Failed Anti-Reflux Operations

Atif Iqbal, MD,* Ziad Awad, MD, FRCSI,† Jennifer Simkins, MD,* Ricky Shah, BS,‡ Mumnoon Haider, MD,* Vanessa Salinas, MD,* Kiran Turaga, MD,* Anouki Karu, MS,‡ Sumeet K. Mittal, MD,* and Charles J. Filipi, MD, FACS*From the *Department of Surgery, Creighton University School of Medicine, Omaha, NE; †Department of Surgery, University of Missouri, Columbia, MO; and ‡Creighton

Objective: assess whether reoperative surgery for failed Nissen fundoplication is beneficial & classify mechanisms of failure

p g y, g y , , ; p g y, y , , ; gUniversity School of Medicine, Omaha, NE.

Study group: 104 pt’s w/ previous fundoplication for GERD who underwent reoperation

Failure Rate: Open fundoplication: 9% to 30%Laparoscopic: 2% to 17%Laparoscopic: 2% to 17%

58 Laparoscopic, 12 open, 34 thoracotomy

Included Nissen, Toupet, & Dor fundoplications, and Collis gastrostomy when indicated (surgeon’s discretion)


Ann Surg. 2006 July; 244(1): 42–51.



Mechanism of Failure


Crus closure failureHiatal stenosisFundoplication disruptionLoose or slipped fundoplicationShort esophagusShort esophagusGastroparesisWrong primary diagnosis


Ann Surg. 2006 July; 244(1): 42–51.



Operative Approach for Failed Procedures


Open thoracotomyRecommended when > 2 cm of gastric tissue within thoracic cavity on esophagramy p gShort esophagus suspected

L tLaparotomyMultiple previous failed operations

LaparoscopyPatient did not meet above criteria


Ann Surg. 2006 July; 244(1): 42–51.



Pitfalls:p g y, g y , , ; p g y, y , , ; g

University School of Medicine, Omaha, NE.

Intraoperative perforations must be closed with sutures incorporating mucosa

Must have intraoperative EGD during surgery

Using a large bougie will allow a good asessment of the Using a large bougie will allow a good asessment of the mobility of the fundic wrap and secure an adequate fundoplication

Must ligate and divide short gastric vessels

Do not hesitate to convert from laparoscopy to open


ReferencesReferences1. Maingot’s Adominal Operations 11th Edition 20072. Schwartz’s Principles of Surgery, 8th Edition 20053. Current Surgical Therapy 9th Edition Cameron 20084. Stylopoulos N, Rattner DW. The history of hiatal hernia surgery: from Bowditch to

laparoscopy. Ann Surg. 2005 Jan; 241(1):185-935. Bombeck TC, Dillard DH, Nyhus LM: Muscular anatomy of the gastroesophageal

junction and role of the phrenoesophageal ligament. Ann Surg 164:643, 1966. 6. DeMeester TR, Stein HJ. Surgical treatment of gastroesophageal reflux disease. In:

Castell DO, ed. The Esophagus. Boston: Little, Brown; 1992:579–626.7. Isolauri J, Luostarinen M, Viljakka M, et al. Long-term comparison of antireflux

surgery versus conservative therapy for reflux esophagitis. Ann Surg. 1997;225:295–299.

8. Weber TR. Toupet fundoplication for gastroesophageal reflux in childhood.Arch Surg 1999 Jul;134(7):717 21 Surg. 1999 Jul;134(7):717-21.

9. Patti MG, Albanese CT, et al. Laparoscopic heller myotomy and dor fundoplication for esophageal achalasia in children. Journal of Pediatric Surg. 2001 Aug;36(8):1248-1251.

10 Terry M Smith CD Branum GD: Outcomes of laparoscopic fundoplication for 10. Terry M, Smith CD, Branum GD: Outcomes of laparoscopic fundoplication for gastroesophageal reflux disease and paraesophageal hernia. Surg Endosc 2001; 15:691.and others

11. Iqbal et al. Reoperation for failed anti-reflux surgery. Ann Surg 2006;244: 42-51.


CommentsComments


QuestionsQuestionsWhich is true?Which is true?

A) Type I hiatal hernia is a rolling herniaA) Type I hiatal hernia is a rolling hernia

B) Type II hiatal hernia is a sliding hernia

C) Type III hiatal hernia is a combined Type I lidi d T II h l h isliding and Type II paraesophageal hernia

D) None of the aboveD) None of the above


QuestionsQuestionsThe first to describe hiatal hernias in The first to describe hiatal hernias in postmortem pt’s was

a) Moser

b) Bowditch

c) Nissen

d) Belsey


QuestionsQuestionsBorchardt’s triad includes of the following except

a) chest pain

b) retching w/ inability to vomit

) i bilit t NGTc) inability to pass NGT

d) gastric distention


QuestionsQuestionsDuring hiatal hernia repair, all of the During hiatal hernia repair, all of the following are important except:

A) have intraoperative EGD

B) make the fundoplication as tight as possible

C) use a large bougie

D) dissect the short gastrics to obtain adequate D) dissect the short gastrics to obtain adequate intraabdominal esophageal length


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