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.