Laparoscopic

          Laparoscopic   Management   OF   Large   Hiatus   Hernia

INTRODUCTION

   

      

   The Management of large hiatal hernias is difficult and their operative repair can be technically challenging . The concept of a large  hiatal  hernia, however, has not been clearly defined. They have been classified by various  authors according to whether the hiatal defect  is larger or  smaller  than 5 cm and or / or their  contents. Aly et al considered hiatal hernias to be large when more than 50 percent  of the stomach has migrated into the chest.  Andujar  defined  it as the presence  of more than one- third of the stomach in the thoracic cavity. Carlson et al in his study has  defined  hiatal  hernias to be large if the  hiatal defect is larger than 8 cm which was later  modified to 5-6 cm. We consider paraesophageal hernias to be large  when more than half of the stomach has migrated into the chest or if the hiatal defect is larger than 5 cm in size.

    

    Hiatal hernias are classified into type I to IV depending on the position of the gastroesophageal junction in relation to the diaphragmatic  hiatus. According to the conventional classification, type III and type IV can be considered to be large hernias. Type III hernias, which is a mixed sliding and paraesophageal hernia (PEH)  occurs predominantly in the elderly population . The end stage of a hiatus hernia  is an intrathoracic stomach in which the whole stomach  migrates into the chest by rotating 180 degrees along its longitudinal axis with the caedia and the pylorus as fixed points  and includes other organs including colon, omentum, small bowel , liver and spleen (TypeIV).

   

     Surgical correction of large hiatal hernias is indicated because of unsatisfactory outcomes after long- term medical  management and potentially disastrous consequences of gastric incarceration or volvulus  in large paraesophageal hernias. Fundamental steps involved in large hiatal hernia repair include a tension free reduction of the esophagus  and the stomach into the abdomen with complete excision of the hernial sac, reapproximation  of the hiatus, and subdiaphragmatic  fixation of the stomach, with many authors advocating the additional of an antireflux procedure.

     Recurrence rates after laparoscopic surgery is a controversial and unresolved  issue. A few early studies have shown alarmingly  high recurrence rates. Some possible patient related and procedure  related mechanisms are  in appropriate postoperative activity  of the patient immediately after surgery, inadequate excision of the sac, inadequate mobilization of the esophagus, inadequate crural closure secondary to widely spaced crura sutured  under  tension , or a postoperative rupture of crurorraphy due to continuous excursion of the diaphragm.

   

     After complete reduction of all the hernial contents, the necessity of complete excision  of the  hernial  sac cannot be understated. IN  earlier series recurrence rates of up to 20 percent have been  reported after inadequate excision  of the hernial  sac . Although  sac removal is tedious and difficult,it is one of the most  crucial  steps of large paraesophageal  hernia repair. If  circumferential  reduction of the sac  is not done and a portion  of the  sac of new  hernia formation has been  practically  left behind. Fluid collections in the unresected sac leading to postoprative dysphagia have also been reported in literature.

   

     A number  of methods have been adopted to reduce the risk of postoperative recurrences and include the use of Teflon pledgets to prevent crural sutures from cutting through, complete detachment of the sac from the hiatus and mediastinum, complete excision of the sac, adequate mobilization of the esophagus and use of mesh cruroplasty in patients with a large hiatus hernia to achieve a tension free hiatal.

SURGICAL PRINCIPLES
    

     

    Although the need for surgical repair is undebated, controversies exist concerning the best surgical  approach  whether open or laparoscopic, the presence of short esophagus and the need for an esophageal lengthening procedure, crurorraphy or a tension free mesh repair, subdiaphragmatic  fixation of the stomach , the need for an antireflux procedure, whether total or partial fundoplication and the indication for prosthetic  reinforcement of the hiatus.

GALLSTONES

                                           GALLSTONES

                 

      Biliary tract  disease is the second  most common  non- obstetric  surgical problem, though it affects only 1 in 1600  to 10000 pregnancies. Cholelithiasis has been documented in 10  percent  of pregnancies and  cholecystitis reportedly affects  0.1 percent  of pregnant patients.

        Pregnancy related  physiological  changes : a. Progesterone causes smooth  muscle relaxation  and  a decrease  in gallbladder tone.  Weakened  contractions and  decreased  emptying  lead to increased  gallbladder  volume  during  fasting  and after eating. In  turn, biliary  stasis  contributes  to cholesterol  crystal sequestration ,  theoretically leading to the  formation  of sludge and stones. b. Elevated  estrogen levels during  pregnancy may further  increase the lithogenicity  of bile. c. Lower  gallbladder  ejection  fractions  and increasing  parity seem  to increase the risk of  sludge formation. A high pre-pregnancy body mass  index  also  may increase the  risk  of sludge  formation. Despite these  physiologic changes, it is unclear if  pregnancy increases  the incidence of gallstones  and  cholecystitis . In  a German  population  study looking  at 1111 females, current pregnancy and the number of prior pregnancies were not associated with an increased  risk.

       The clinical presentation of acute  cholecystitis is similar  to the non- pregnant patient. The pregnant - patient who has right upper  quadrant  tenderness  should undergo ultrasound  evaluation  first because it is  noninvasive and quickly obtained.  MR cholangiography can be suspected  but not demonstrated on  ultrasound.  Symptomatic  cholelithiasis often is managed initially with  a conservative approach,  delaying elective cholecystectomy until after delivery. If conservative  management fails, or if repeated hospitalizations are required, especially  in the same  trimester, cholecystectomy is indicated. Recent studies have  shown, earlier surgical intervention  for biliary tract disease in pregnancy is safe with reduced hospital stay, reduced use of  medications, lower rates  life- threatening complications and lower preterm deliveries. The  laparoscopic cholecystectomy  has been performed safely in all trimesters. The use of an  open  technique for entry, insufflations to 12 mm Hg, and  maintaining a left lateral decubitus  position minimize risk to the fetus and  help maintain adequate placental blood flow during  surgery.

        Patients presenting with acute cholecystitis and symptomatic choledocholithiasis  during pregnancy  should be considered  in a higher  risk  category. If  complications such  as cholangitis or gallstone  pancreatitis develop, maternal mortality  approaches 15 percent, and fetal loss occurs in 60 percent of cases . 

        Surgical approaches  include open cholecystectomy with choledochotomy  or laparoscopic  cholecystectomy with ERCP (endoscopic retrograde cholangiopancreatography ) with sphincterotomy  for  stone extraction or stent placement has been shown  to be  safe during pregnancy.  Although  not routinely recommended, intraoperative  cholangiography   is safe  after fetal organogenesis is complete  and does not increase the risk   of preterm  labor or adverse fetal outcomes.

APPENDIX

                                                      APPENDIX

       

     Appendicitis is the most common non- obstetric surgical complication and the most common gastrointestinal disorder  requiring  surgery during pregnancy. It accounts  for 25 percent of surgeries for non- obstetric  indications in  pregnancy and complicates every  1 in 1500 to 2000 pregnancies. The incidence of perforated  appendicitis in pregnant women is 43 percent compared to 4-9 percent in the non- obstetric  population.  This increased  incidence may be due to delay in diagnosis and reluctance to operate in pregnancy. Maternal and fetal morbidity and  mortality correlate with perforation and  its associated complications. Uncomplicated appendicitis has a 3-5 percent  fetal loss rate with negligible maternal mortality. Appendix perforation, however, is associated with a 20-35 percent fetal loss rate and 4 percent maternal mortality. Appendix  perforation , however , is associated  with  a 20-35 percent  fetal  loss rate and 4 percent  maternal  mortality. Maternal  mortality rates have  dropped  significantly in the  recent  years with prompt surgical  intervention , newer antibiotics and  surgical  techniques. 

      The preterm contractions  caused  by  uterine irritation from perforation peritonitis result in preterm delivery in 5-14 percent. This incidence is similar between  open  and laparoscopy. In the  first trimester the  appendix remains in its  normal anatomic  position. The appendix  undergoes progressive displacement cephalad  and laterally with advancing pregnancy. After 24 weeks gestation, the  appendix is shifted superiorly  above the right iliac crest , and the tip of the appendix is rotated  medially toward the uterus. By  late pregnancy, the appendix may be closer to the gallbladder than MCBurney's point, occupying the right upper quadrant . This change may alter the location of the pain, making diagnosis difficult. As the  peritoneum is displaced  from the appendix  and cecum by the growing uterus, the increased separation of  the visceral  and parietal peritoneum  decreases  the somatic  sensation of pain and compromises the ability to  localize pain  on examination. The enlarging uterus interfere with the ability  of the omentum and bowel to wall off the inflamed appendix.  Diffuse peritonitis from perforation is  facilitated by this inability of the omentum to isolate the infection. The appendix  returns  to its normal  position by the tenth postpartum day. However, modern clinical experience does not confirm this assertion, with recent studies demonstrating  that the most frequent  location of pain  remains in the right lower quadrant, regardless of trimester. 

               

     Symptoms of appendicitis often  are confused with normal  pregnancy related conditions, particularly in the third trimester. Pain in the right lower quadrant is the most  common and reliable symptom  of appendicitis along with the usual features of appendicitis. Rectal  and pelvic tenderness may not be present when the appendix  is displaced by the uterine enlargement. Leukkocytosis is normal in pregnancy  and so not a good  indicator. Ultrasound Scan is useful  in the first  and second trimester. MRI is safe in pregnancy . CT  Scan should be reserved for cases where Ultrasound and MRI are non- diagnostic. Despite reluctance to operate on a pregnant patient, immediate surgical  intervention is indicated when a  diagnosis of appendicitis is made. The choice of surgical procedure is  based on uterine size and experience  of the  surgeon.  The only indication  of delay  is active labor, and in these  cases the surgery is performed immediate  postpartum.

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      Diagnostic and operative  laparoscopy  is reasonable  before 20 weeks gestation  and is as safe as open surgery. When  performing  laparoscopy  open entry(Hassan)  is preferable to avoid inadvertent veress or trocar  entry into uterus. Trocar placement  needs to be changed according  to the  size of the uterus. Beyond the late second trimester, laparoscopy  becomes more technically challenging . Appendicitis is confirmed in 36-50  percent of cases. Accuracy of diagnosis  in the  first trimester is greater.  A higher false positive rate is acceptable  in pregnant women, because  any delay in diagnosis may compromise maternal and fetal  well - being .