1. Morgan Randall

2. Paraesophageal Hernia

3. 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

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

6. 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

7. 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

8. 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

9. 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),

10. 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

11. Room Setup

12. Port Placement

13. 10mm Port 5mm Port 12mm Port 5mm Port 15 cm

14. Room Setup

15. Place Liver Retractor

16. Important Structures http://upload.wikimedia.org/wikipedia/commons/4/4b/Gray793.png http://www.biology-online.org/articles/computer_simulation_analysis_normal/figures.html http://www.med.umich.edu/anatomy/plastinate/galleries/Green_Lab/Abdominal_Cross_Section.html

17. Hernia Dissection

18. Mobilize Fundus of Stomach

19. Place Penrose Drain

20. Hernia

21. Stitch Hernia Closed

23. Add Mesh and Staple in Place

24. Nissen Fundoplication

25. Endoscopy to Check Alignment

26. Questions?

27. Thank You

28. Refrences Special Thanks to Dr. John Roth Benign Esophageal Disease. Thoracic Surgery. Stanford School of Medicine. http://thoracicsurgery.stanford.edu/patient_care/benign_esophageal.html Pierre, Andrew F. and Luketich, James D. Laproscopic Repair of Giant Paraesophageal Hernias. Cardiothoracic Surgery Network. http://www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-9.html Paraesophagel Hernia. Mount Sinai School of Medicine. http://www.mssurg.net/Team5Conferences/Paraesophageal%20Hernia%20- 2.pdf Laparoscopic Paraesophageal Hernia. Ohio State University Center for Minimally Invasive Surgery. The Ohio State University. Department of Surgery. http://cmis.osu.edu/8818.cfm www.websurg.com UK HealthCare. Hernia Facts Sheet. http://www.ukhealthcare.uky.edu/publications/healthfocus/fact_sheets/herni as.asp

29. Endo Universal 65 http://www.covidien.com/hernia/us/fixation/endouniversal RETURN

30. 30° Endoscope http://www.stryker.com/en-us/products/Endoscopy/Laparoscopy/Laparoscopes/StandardLengthLaparoscopes/index.htm RETURN

31. Trocar Available in 5mm, 8mm, 10mm, 12mm http://www.ethiconendosurgery.com/Clinician/Product/access/trocars/xcelbladeless#About RETURN

32. Biologic Implant Mesh http://www.covidien.com/hernia/us/biologics/permacol RETURN

33. Maryland Dissector http://www.ethiconendosurgery.com/Clinician/Product/endodevices/endohandinstruments#description-specs RETURN

34. Penrose Drain http://www.covidien.com/criticalcare/pageBuilder.aspx?webPageID=0&topicID=67861&xsl=xsl/productPagePrint.xsl RETURN

35. 56 French Bougie http://www.stryker.com/en-us/products/Endoscopy/Laparoscopy/AccessoriesandDisposables/InfraVisionEsophagealKit/index.htm RETURN

36. Articulating Grasper http://www.covidien.com/autosuture/pagebuilder.aspx?topicID=195028&breadcrumbs=0:63659,172308:0,195057:0 RETURN

37. Suction/Irrigation System http://www.endotek.com.tr/default.asp?L=EN&mid=173&cat_id=216 RETURN

38. Scalpel http://www.google.com/search?hl=en&sugexp=ldymls&xhr=t&q=scalpel&cp=6&bav=on.2,or.r_gc.r_pw.&wrapid=tljp1303234486536010&um=1&ie =UTF-8&tbm=isch&source=og&sa=N&tab=wi&biw=1259&bih=617 RETURN

39. Harmonic Scalpel http://www.ethiconendosurgery.com/Clinician/Product/energy http://www.hhsurgical.com/Products/Product/Electrosurgical-Units/NoSub/1445-Ethicon-G110-Harmonic-Scalpel-.chtml RETURN

40. Syringe http://www.mediray.com/Pages/Products/SyringeShields.html RETURN

41. Liver Retractor http://www.bristolsurgery.com/article.aspx?articleid=100749 RETURN

42. Suture http://www.syneture.com/syneture/pageBuilder.aspx?topicID=315 http://www.sosmedicalsuperstore.com/PhotoGallery.asp?ProductCode=A306H RETURN