Laparoscopic Paraesophageal Hernia Repair

1. Introduction

2. Portal Placement

• • Pneumoperitoneum achieved via a Veress needle and subsequent placement of a supraumbilical camera port under direct visualization.

1. Place Left Side Instrument Trocar
2. Retract Left Lateral Segment of Liver
3. Place Second/Third Trocars Completing Triangle

3. Mobilize Hernia Sac from Crus

1. Dissect Gastrohepatic Ligament
   • Must always be aware of the potential for an accessory or replaced left hepatic artery within the gastrohepatic ligament.
2. Dissect Hernia Sac off Left Crus
3. Dissect Hernia Sac off Right Crus
4. Dissect Posterior Aspect of Hernia Sac
5. Identify Posterior Vagus Nerve
6. Transect Short Gastric Arteries
7. Dissect Hernia Sac from Greater Curvature of Stomach
8. Expose Esophagus Cephalad to Sac and Identify Anterior Vagus Nerve

4. Separate Stomach from Hernia Sac

1. Dissect the Stomach off the Inner Layer of the Hernia Sac
2. Excision of Hernia Sac
3. Continue Hernia Sac Dissection of Stomach
4. Dissect Lesser Curvature of Stomach

5. Dissection of GE Junction and Esophagus

1. Further Mobilization of the Esophagus
2. Dissect Mediastinal Pleura Tissue from Spine/Aorta
3. 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.
4. Continue Dissection of Posterior Hernia Sac from Stomach
5. Dissect Lower End of Left Crus

6. Crural Closure

1. 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.
2. 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

6. Toupet Fundoplication and Gastropexy

1. Align Short Gastric Arteries
   • Align the short gastric arteries along the top of the fundoplication.
   • Fundoplication performed with a 5.5-inch silk stitch.
2. Posterior Gastropexy

8. Excision of Suspected Benign Mass

9. Port Site Closure