Morgan Randall

Paraesophageal Hernia

Indications Patients with a PEH will present with: Gastroesophageal Reflux Disease (GERD) Dysphagia Epigastric Pain Vomiting Barrett’s Epithelium Postprandial Fullness or Pain Pulmonary Dysfunction

Preoperative Tests Chest X-Ray Barium Esophagram Esophagogastroduodenoscopy Esophageal pH Study CT Scan (rare) MRI (rare) Pulmonary Function Test (rare)

Classification Type I not considered a true PEH Upward migration of the GE junction into the mediastinum Hernia sac consists of visceral peritoneum, paraesophageal membrane, anterior wall of gastric cardia Type II Upward dislocation of fundus of stomach alongside a normally positioned intraabdominal GE junction

Classification cont. Type III Upward displacement of both GE junction and gastric fundus More common than Type II Type IV – aka Giant Contains viscera other than stomach

Laproscopic vs Open Advantages of Laproscopic Procedure Quicker Recovery Decreased Length of Hospital Stay Quicker Return to Normal Activities Reduced Recurrence Rate Fewer Infections Smaller Incisions Advantages of Open Increased Abdominal Access

Contraindications Contraindications for the laparoscopic approach Absolute contraindications: abdominal or mediastinal perforation. Relative contraindications single or multiple recurrences in patients with multiple abdominal scars (the thoracic route may be indicated in these patients),

Instruments Used Scalpel Syringe 5mm, 10mm, 12mm Trocars 30° Laproscope Liver Retractor Harmonic Scalpel Atraumatic Graspers Articulating Grasper Penrose Drain 56 French Bougie Suction/Irrigation System Endo Universal 65 Stapler Bioilogic Implant Mesh Suture 0 Braided Silk 2-0 Braided Silk

Room Setup

Port Placement

10mm Port 5mm Port 12mm Port 5mm Port 15 cm

Room Setup

Place Liver Retractor

Important Structures

Hernia Dissection

Mobilize Fundus of Stomach

Place Penrose Drain

Hernia

Stitch Hernia Closed

Add Mesh and Staple in Place

Nissen Fundoplication

Endoscopy to Check Alignment

Questions?

Thank You

Refrences Special Thanks to Dr. John Roth Benign Esophageal Disease. Thoracic Surgery. Stanford School of Medicine. Pierre, Andrew F. and Luketich, James D. Laproscopic Repair of Giant Paraesophageal Hernias. Cardiothoracic Surgery Network. Paraesophagel Hernia. Mount Sinai School of Medicine. 2.pdf Laparoscopic Paraesophageal Hernia. Ohio State University Center for Minimally Invasive Surgery. The Ohio State University. Department of Surgery. UK HealthCare. Hernia Facts Sheet. as.asp

Endo Universal 65 RETURN

30° Endoscope RETURN

Trocar Available in 5mm, 8mm, 10mm, 12mm RETURN

Biologic Implant Mesh RETURN

Maryland Dissector RETURN

Penrose Drain RETURN

56 French Bougie RETURN

Articulating Grasper RETURN

Suction/Irrigation System RETURN

Scalpel =UTF-8&tbm=isch&source=og&sa=N&tab=wi&biw=1259&bih=617 RETURN

Harmonic Scalpel RETURN

Syringe RETURN

Liver Retractor RETURN

Suture RETURN