**4.1 Classification**

Anatomically four different types of hiatal hernias can be recognised:


Up to 95% of all hiatal hernias can be classified as a type 1, sliding hernia. Type 3 and type 4 hiatal hernias tend to be large or giant hernias. Large or giant hernias are defined as at least 30%-50% of the stomach herniating into the thoracic cavity. Patients with hiatal hernia can experience symptoms of GERD, as epigastric pain, dysphagia, heartburn, but in more severe cases gastric hemorrhaging, vomiting and cardiopulmonary problems with dyspnea. Paraesophageal hernias account for less than 5% of all hiatal hernias but can have potentially life-threatening complications, such as obstruction, dilatation, necrosis with perforation or bleeding of the stomach.

#### **4.2 Laparoscopic repair**

Patients with sliding hernias and GERD should be considered for elective surgical repair. The objectives of hiatal hernia surgery for GERD are repair of the intrinsic component of the anti-reflux mechanism by bringing back LES into the hiatal tunnel and repair of the extrinsic component of the anti-reflux mechanism by narrowing the hiatus. Paraesophageal hernias (type 2, 3 and 4) should be repaired when symptomatic, due to the associated possible lifethreatening complications. The laparoscopic approach to hiatal hernia repair has the benefit of easy exposure of the hiatus area and a good vision into the mediastinum. To restore the intrinsic component of anti-reflux mechanism a laparoscopic fundoplication is performed. The laparoscopic Nissen fundoplication (360° wrap) is the most frequently applied procedure. Other possible fundoplications are the posterior Toupet (270° wrap) and anterior Dor (180° wrap). The laparoscopic Nissen fundoplication is equally effective in patients with GERD or with paraesophageal hernia and is the preferred fundoplication procedure. The failure rate of a Nissen fundoplication for GERD is between 2-30%, depending whether failure is defined as resumption of conservative treatment or failure requiring reoperation.

Laparoscopic Hernia Repair 175

Laparoscopic repair of paraesophageal hernias is superior to open repair, with an associated decreased length of hospital stay, complication rate and recurrence rate (Draaisma et al., 2005). Long-term good functional results are observed in 75% and (symptomatic) recurrences in 15% after large paraesophageal hernia repair (Poncet et al., 2010). Postoperative complications associated with laparoscopic large paraesophageal hernia repair are intrathoracal wrap migration, relative stenosis of the cardia, gastric volvulus or strangulation, pneumothorax, pneumonia and dysphagia. A synthetic mesh can be used to reinforce the hiatal repair, but is still controversial. A mesh might be associated with a decreased recurrence rate, but may give rise to serious complications like prosthetic migration, esophageal perforation, dysphagia and mesh infection. Since the majority of paraesophageal hernias are mixed sliding and paraesophageal hernias, an insufficient LES with GERD-symptoms may remain after surgery and antireflux medication is still required.

Fig. 2. Anatomic landmarks and structures of importance in hiatal hernia repair (Lange & Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002)

Esophagus (1) Gastric fundus (2) Splenic capsule (3)

Phrenico-esophageal ligament (4) Abberant left hepatic artery (5) Anterior vagus nerve (6) Hepatic branch (7) Posterior vagus nerve (8)

The failure rate of a Nissen fundoplication for paraesophageal hernia is 7-33%, depending whether failure is defined anatomically or symptomatically. Patient satisfaction after laparoscopic Nissen fundoplication with 5-year follow-up is 86-96% (Lafullarde et al., 2001; Smith et al., 2005). Complications associated with laparoscopic hiatal hernia surgery include stenosis, pulmonary complications (pneumonia, pneumothorax, pulmonary edema) and gastrointestinal complications (bleeding, perforation, dysphagia).

#### **4.2.1 Laparoscopic fundoplication technique**

The patient should be positioned supine on a split leg table with arms out and in a steep reverse Trendelenburg position to help expose the hiatus. After establishing a pneumoperitoneum five trocars are inserted. A liver retractor is used to retract the left liver lobe and expose the anterior surface of the proximal stomach near the gastroesophageal junction. The hepatogastric omentum should be opened over the caudate lobe of the liver, just above the hepatic branch of the vagal nerve, exposing the right crus of the diaphragm. Caution should be taken for an aberrant left hepatic artery in this area, present in approximately 20% of patients. Over left, anteriorly the phrenoesophageal ligament can be divided to its apex on the right. The right and left crus are dissected from its base to the crural arch and the retroesophageal window is gently opened, protecting the posterior vagal nerve. A penrose drain can be used to retract the esophagus during further dissecting, until at least 2-3 cm of distal esophagus can be pulled below the diaphragm without tension. During this dissection caution should be taken not to injure the anterior and posterior vagal nerves, left or right pleura and aorta. The gastric fundus should be mobilized from 10-15 cm inferior to the angle of His, isolating and dividing the short gastric vessels, working back to the gastroesophageal junction. It is important to avoid excessive traction when dividing all posterior gastric arteries and other attachments, to prevent tearing of the short gastric arteries or splenic capsule. In some patients the proximal fundus and upper pole of the spleen are closely attached, making this part of the dissection quite difficult. The mobilized gastric fundus is brought through the retroesophageal window and around the distal esophagus anteriorly to ensure adequate mobilization. If the gastric fundus is released and exits the retroesophageal window, further mobilization is necessary. The fundoplication can be completed around a 50-60 French dilator. The internal diameter of the wrap should exceed the external diameter of the esophagus. Two or three non-absorbable sutures are placed with bites taking full thickness gastric fundus and partial thickness anterior esophageal wall, avoiding the anterior vagal nerve. When completed the wrap should be no greater than 2 cm in length and optimally a bit of distal esophagus should be visible distally to the wrap. Additional sutures from the wrap to the diaphragm can be placed. The crus can be closed using non-absorbable stitches.

#### **4.2.2 Paraesophageal hernia repair**

Laparoscopic repair of a paraesophageal hernia consists of reduction of the stomach and gastroesophageal junction into the abdominal cavity, complete excision of the peritoneal hernia sac from the mediastinum, and repair of the esophageal hiatus. Following a Nissen fundoplication, the crus should be closed using non-absorbable sutures. In case of a large hiatus, additional anterior or lateral crural stitches can be added. An additional anterior gastropexy can be performed in case of a very large or shortened esophagus. The anterior stomach wall and the antrum should be sutured to the abdominal wall.

The failure rate of a Nissen fundoplication for paraesophageal hernia is 7-33%, depending whether failure is defined anatomically or symptomatically. Patient satisfaction after laparoscopic Nissen fundoplication with 5-year follow-up is 86-96% (Lafullarde et al., 2001; Smith et al., 2005). Complications associated with laparoscopic hiatal hernia surgery include stenosis, pulmonary complications (pneumonia, pneumothorax, pulmonary edema) and

The patient should be positioned supine on a split leg table with arms out and in a steep reverse Trendelenburg position to help expose the hiatus. After establishing a pneumoperitoneum five trocars are inserted. A liver retractor is used to retract the left liver lobe and expose the anterior surface of the proximal stomach near the gastroesophageal junction. The hepatogastric omentum should be opened over the caudate lobe of the liver, just above the hepatic branch of the vagal nerve, exposing the right crus of the diaphragm. Caution should be taken for an aberrant left hepatic artery in this area, present in approximately 20% of patients. Over left, anteriorly the phrenoesophageal ligament can be divided to its apex on the right. The right and left crus are dissected from its base to the crural arch and the retroesophageal window is gently opened, protecting the posterior vagal nerve. A penrose drain can be used to retract the esophagus during further dissecting, until at least 2-3 cm of distal esophagus can be pulled below the diaphragm without tension. During this dissection caution should be taken not to injure the anterior and posterior vagal nerves, left or right pleura and aorta. The gastric fundus should be mobilized from 10-15 cm inferior to the angle of His, isolating and dividing the short gastric vessels, working back to the gastroesophageal junction. It is important to avoid excessive traction when dividing all posterior gastric arteries and other attachments, to prevent tearing of the short gastric arteries or splenic capsule. In some patients the proximal fundus and upper pole of the spleen are closely attached, making this part of the dissection quite difficult. The mobilized gastric fundus is brought through the retroesophageal window and around the distal esophagus anteriorly to ensure adequate mobilization. If the gastric fundus is released and exits the retroesophageal window, further mobilization is necessary. The fundoplication can be completed around a 50-60 French dilator. The internal diameter of the wrap should exceed the external diameter of the esophagus. Two or three non-absorbable sutures are placed with bites taking full thickness gastric fundus and partial thickness anterior esophageal wall, avoiding the anterior vagal nerve. When completed the wrap should be no greater than 2 cm in length and optimally a bit of distal esophagus should be visible distally to the wrap. Additional sutures from the wrap to the diaphragm can be placed. The crus can

Laparoscopic repair of a paraesophageal hernia consists of reduction of the stomach and gastroesophageal junction into the abdominal cavity, complete excision of the peritoneal hernia sac from the mediastinum, and repair of the esophageal hiatus. Following a Nissen fundoplication, the crus should be closed using non-absorbable sutures. In case of a large hiatus, additional anterior or lateral crural stitches can be added. An additional anterior gastropexy can be performed in case of a very large or shortened esophagus. The anterior

stomach wall and the antrum should be sutured to the abdominal wall.

gastrointestinal complications (bleeding, perforation, dysphagia).

**4.2.1 Laparoscopic fundoplication technique** 

be closed using non-absorbable stitches.

**4.2.2 Paraesophageal hernia repair** 

Laparoscopic repair of paraesophageal hernias is superior to open repair, with an associated decreased length of hospital stay, complication rate and recurrence rate (Draaisma et al., 2005). Long-term good functional results are observed in 75% and (symptomatic) recurrences in 15% after large paraesophageal hernia repair (Poncet et al., 2010). Postoperative complications associated with laparoscopic large paraesophageal hernia repair are intrathoracal wrap migration, relative stenosis of the cardia, gastric volvulus or strangulation, pneumothorax, pneumonia and dysphagia. A synthetic mesh can be used to reinforce the hiatal repair, but is still controversial. A mesh might be associated with a decreased recurrence rate, but may give rise to serious complications like prosthetic migration, esophageal perforation, dysphagia and mesh infection. Since the majority of paraesophageal hernias are mixed sliding and paraesophageal hernias, an insufficient LES with GERD-symptoms may remain after surgery and antireflux medication is still required.

Esophagus (1) Gastric fundus (2) Splenic capsule (3) Phrenico-esophageal ligament (4) Abberant left hepatic artery (5) Anterior vagus nerve (6) Hepatic branch (7) Posterior vagus nerve (8)

Fig. 2. Anatomic landmarks and structures of importance in hiatal hernia repair (Lange & Kleinrensink, Surgical Anatomy of the Abdomen, Elsevier gezondheidszorg, 2002)

Laparoscopic Hernia Repair 177

defect. A mesh should provide at least 5 cm of overlap of the fascial edges and should be

Several different 'keyhole techniques' have been described, which have in common that a mesh is placed with a central hole or slit in the mesh to allow the bowel to pass through the mesh to the stoma site. One of the main drawbacks is shrinkage of the mesh that can result in obstruction or recurrent herniation by enlargement of the hole. In the modified Sugarbaker technique no hole is made in the mesh but the bowel to the stoma is lateralized and covered by the mesh (Berger & Bientzle, 2007; Mancini et al., 2007; Sugarbaker, 1985). The mesh is secured to the abdominal wall at the margin of the mesh at 5 cm intervals. A second row of tackers is placed at the margin of the hernia defect with additional tackers at each side of the colon. Both techniques are promising, however long term results are not yet available. Perhaps prevention of development of parastomal hernia by placement of a

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