Editing Hiatal hernia (section)

== Paraoesophageal hernia repair ==

* Can be done open, lap, or     transthoracic
* First, endoscopy
* Lap probably best first     option although never been compared directly

=== Indications: ===

* Patients with volume reflux
* Symptoms respond to PPI
* GORD with negative test for     oesophageal dysmotility
** Lithotomy, both arms at      90deg. Surgeon between legs.
** Nathanson retractor to pull      up left lobe of liver
** Divide lesser omentum to      expose the right hiatal liver
*** Be aware of hepatic branch       of vagus nerve and aberrant left hepatic artery
** Dissect hernial sac and      completely remove from mediastinum - circumferential dissection
** Mobilise oesophagus
** Tension-free repair of      hiatal defect, generally without mesh. Mostly interrupted sutures - maybe
** Perform complete Nissen      fundoplication
** Anterior gastropexy to      reduce risk of reherniation

=== Complications ===
** Intra-operative
*** Hepatic/splenic injury
*** Bleeding from short       gastrics
*** Perforation of oesophagus
*** Inability to reduce       oesophagus - happens with long-term GORD - scarred
*** Pneumothorax - common -       won't be any consequences, will disappear after laparoscopy
** Long-term
*** Dysphagia, gas bloat,       difficulty to belch
*** Vagotomy
** Dysphagia
*** Too tight wrap
*** Disruption of wrap
*** Sliding HH - stomach slides       up under wrap
*** Slipped fundoplication -       wrap falls down
*** Intra-thoracic migration

=== Post-op ===
** Antiemetics - don't want      vomiting
** Barium swallow D1 post op -      look for leak/recurrence, evaluate gastric emptying
** If swallow ok, start of      clear fluids
** Discharge after a couple of      days generally
** Start soft/puree diet D4,      then normal diet in four weeks. Avoid large meals early.
** Expect some degree of      dysphagia for 4 weeks or so.

=== Outcomes ===
** 90% have long-term symptoms      relief
** 40% have some degree of      radiographic recurrence

=== Controversies ===
** Open vs laparoscopic
*** Lap should now be standard       of care, even for massive and/or recurrent
*** If lap fails, left       thoracotomy would be best approach
** Also do antireflux?
*** Almost certainly yes
** Mesh?
*** Long-term risk of erosion       is unknown
*** Onlay biologic prosthetic       mesh if needed in preference to synthetic
** Ligation of short gastrics -      no evidence it improves wrap, but it does make it easier to flip fundus      over

[[Category:UGIS]]