Hiatus hernia repair

Principles

• Reduction of the hernia contents to the abdominal cavity
• Complete excision of the hernia sac from the posterior mediastinum
• Mobilisation of the distal oesophagus to achieve a minimum of 3cm intra-abdominally
• Anti-reflux operation

Technique:

• Laparoscopic entry and ports as per anti-reflux surgery
• Divide pars flaccida proximal to hepatic division of the vagus and expose right pillar of hiatus
• Reduce hernia contents to obtain 3cm of intra-abdominal oesophagus
  • First using gentle traction, incise between phreno-oesophageal membrane and oesophagus over the right crus
  • Work around anteriorly towards the left crus
  • Then mobilise the fundus of the stomach by dividing the short gastric vessels and thus expose the left crus (also need to divide the sac to see the crus)
  • Enter the posterior mediastinum outside the hernia sac, between the phreno-oesophageal membrane and the left crus, and divide the peritoneal sac anteriorly (parallel to the left crus). This should improve mobilisation of the sac.
  • Mobilise posterior sac - beware of posterior vagus nerve. Can use a lighted bougie in the oesophagus to clearly identify it.
• Reapproximate the crura with interrupted non-absorbable suture
  • If it can't be reapproximated, either close the hiatus under tension with reinforcing biologic mesh, or if the crura is so non-pliable that you can't do that, perform a diaphragm-relaxing incision on the right crus with reinforcing biologic mesh
  • 7x10cm piece of biologic mesh cut into a horseshoe, in either a U or C configuration, and sutured to the diaphragm, with fibrin glue to reinforce
  • Biologic mesh has been shown to decrease early recurrences from 24% to 9%, but the 5 year recurrence rate was the same.
  • The other option is to use a permanent PTFE mesh to cover the relaxing incision

• Perform an anti-reflux procedure - most likely a Nissen, unless they have a problem with the oesophagus, in which case you could do a partial wrap
  • See separate topic
• Consider excising sac
  • Most just leave it, but it can become ischaemic and cause inflammatory response

Post-op and complications

• As per anti-reflux topic