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Laparoscopic repair of a large paraesophageal hernia is built around a few non‑negotiable principles: complete sac reduction, aggressive mediastinal mobilization to obtain ≥2–3 cm tension‑free intra‑abdominal esophagus, meticulous crural reconstruction, and a tailored fundoplication or gastropexy.
Preoperative evaluation and case selection
Patients usually present with a mix of reflux and obstructive symptoms (post‑prandial pain, vomiting, dysphagia, dyspnea, anemia), and a careful symptom profile guides the choice between fundoplication versus gastropexy alone. Barium swallow defines hernia type, percentage of stomach in chest, GEJ position, volvulus, and esophageal motility pattern, while endoscopy assesses mucosa and excludes Barrett’s or malignancy. CT is reserved for giant or complicated hernias (volvulus, incarceration, organoaxial twist) or redo surgery to delineate anatomy.[2][1]
Baseline labs (Hb for iron‑deficiency, albumin for nutrition) and pulmonary function tests are recommended in elderly or dyspneic patients to distinguish lung compression from intrinsic lung disease. Manometry and pH studies are used selectively, as large paraesophageal hernias often distort anatomy and make catheter studies difficult and less reliable.[2]
Anesthesia, positioning and port placement
Under general anesthesia with muscle relaxation, patients receive thromboprophylaxis (sequential compression devices and low‑dose heparin) and a Foley catheter. The standard position is supine, legs apart or together, arms abducted to about 45° with careful padding, and a well‑padded footboard to allow steep reverse Trendelenburg.[1][2]
The surgeon usually stands on the patient’s right, assistant on the left, with a 30° scope. A five‑port layout is typical: an open Hasson 10 mm port in the right paramedian line in the upper third between xiphoid and umbilicus, a 10 mm camera port in the left paramedian line at the same level, bilateral 5 mm working ports in the mid‑clavicular subcostal region, and a 5 mm subcostal or far‑lateral port for liver retraction; an extra periumbilical 5 mm port can be added for gastric traction.[1][2]
Initial exploration and creation of working space
After insufflation to 12–15 mmHg, a fan‑type or articulating retractor elevates the left lobe of liver to fully expose the hiatus. The table is placed in steep reverse Trendelenburg to allow abdominal viscera to fall caudally and create space at the hiatus.[1]
In giant type III/IV hernias, herniated stomach, colon, or omentum is gently decompressed and partially reduced, avoiding traction on the stomach wall; epiploic appendages are preferred for grasping colon. The true hernia sac is identified as a peritoneal extension from the cardia and is grasped just above the crura at the 12 o’clock position by surgeon and assistant to begin sac eversion.[2][1]
Step 1: Sac reduction and entry into mediastinum
The sac is everted circumferentially until the transition from sac to normal peritoneum is seen, then opened anteriorly at the line of peritoneal reflection using ultrasonic shears or similar energy device. Dissection proceeds in the areolar plane between the sac and mediastinal structures, which is relatively avascular and facilitates safe mobilization while avoiding vagal injury.[2][1]
The sac is progressively stripped off pericardium, pleura and aorta, using sharp energy dissection rather than blunt tearing to minimize bleeding and preserve visualization. The goal is complete reduction of the hernia sac into the abdomen; traction on the sac, not on the stomach, returns the stomach to its anatomical position and reduces the risk of gastric tears.[1][2]
Step 2: Circumferential mediastinal esophageal mobilization
Once the sac is reduced, attention turns to full 360° mediastinal mobilization of the esophagus up to or above the level of the inferior pulmonary veins. Dissection begins anteriorly along the pericardium, proceeds laterally to free pleural attachments (particularly on the left), and continues posteriorly until the aorta is visualized, working outside the esophageal fat pad to protect the vagus nerves.[2][1]
Both anterior and posterior vagus nerves must be identified and preserved; any longitudinal band running parallel to the esophagus is treated as a nerve until proven otherwise. Entry into the pleural spaces is avoided because pneumothorax can destabilize hemodynamics and compromise visualization, although a deliberate pneumothorax can later be used as an adjunct to facilitate crural closure in difficult cases.[1][2]
Step 3: Separation of sac from crura and preservation of crural lining
After mediastinal esophageal mobilization, the residual sac is carefully dissected off the right and left crura, keeping the peritoneal lining over the crural muscle intact. This peritoneal layer is crucial, as denuded muscle fibers hold sutures poorly and predispose to repair failure and recurrence.[2][1]
Mobilization is extended to divide phrenosplenic and phrenogastric attachments, which markedly increases mobility of the left crus and facilitates tension‑free crural approximation even in large defects. The dissection plane from the mediastinum is joined with that from the abdomen to complete circumferential release of the sac and crura.[1][2]
Step 4: Lesser curve and right crus dissection
The gastrohepatic ligament is divided in its avascular portion, entering the lesser sac and exposing the right crus. As the right crus is approached, the surgeon carefully finds a plane between sac and the crural peritoneum, avoiding inadvertent stripping of the crural lining.[2][1]
Residual attachments of the sac to the right crus and right pleura are freed, and dissection follows down to the aortic plane, uniting with the earlier mediastinal mobilization. Throughout, the posterior vagus nerve is protected as it courses along the posterior esophagus.[1]
Step 5: Greater curve and left crus, division of short gastrics
Omentum is swept laterally, and the terminal gastroepiploic branches are distinguished from the short gastric vessels. Short gastrics are divided close to the gastric wall with energy device and clips, taking care to avoid splenic injury.[1]
Dissection continues along the upper greater curvature to free thickened hernia sac attachments between spleen and left crus, again preserving the peritoneal shell over the crura and diaphragm. Complete release of phrenosplenic attachments allows the left crus to be mobilized medially and contributes significantly to a tension‑free hiatal closure.[2][1]
Step 6: Esophageal fat pad mobilization and assessment of length
The esophageal fat pad is mobilized off the anterior distal esophagus and gastric cardia to reveal the true gastroesophageal junction and angle of His. This avoids mistaking tubularized cardia for esophagus and permits accurate measurement of intra‑abdominal esophageal length in a neutral position.[2][1]
The goal is at least 2–3 cm (many authors prefer 2.5–3 cm) of tension‑free esophagus below the diaphragm after mediastinal mobilization. During fat pad dissection, both vagus nerves are gently swept off the esophagus so that the subsequent fundoplication sits on the esophagus rather than on bulky fat and to protect the anterior vagus if a Collis gastroplasty is required.[1][2]
Step 7: Collis gastroplasty for short esophagus (when needed)
If, despite maximal mediastinal mobilization, less than 2 cm of intra‑abdominal esophagus is available, a wedge‑type Collis gastroplasty is performed over a large bougie (commonly 54 Fr). The bougie is positioned along the lesser curvature, and sequential stapler firings perpendicular then parallel to the bougie create a tubular neoesophagus, targeting approximately 3 cm of intra‑abdominal neoesophageal segment.[2][1]
Care is taken not to resect excess fundus, which would compromise fundoplication geometry and risk wrap tightness. After Collis, the neofundic tip is brought posteriorly through the retroesophageal window to construct the fundoplication at least 2–3 cm below the hiatus.[1]
Step 8: Hiatal closure (cruroplasty) with or without mesh
Crural repair usually follows or precedes the wrap depending on surgeon preference; both sequences are acceptable as long as visualization is maintained and the wrap is not grasped during suturing. Posterior approximation of the right and left crura is performed with interrupted non‑absorbable or slowly absorbable heavy sutures (often 0 gauge), aiming for a snug but non‑constricting hiatus around the esophagus.[2][1]
Typically, two or more posterior sutures are placed, then the residual gap is assessed and additional anterior or lateral sutures are added to restore a natural esophageal lie and avoid a “posterior ridge” that could kink the esophagus. Many high‑volume centers report that with meticulous mobilization and preservation of crural peritoneum, a tension‑free primary suture repair is feasible in roughly 80–85% of cases, reserving mesh (usually biologic) for attenuated, denuded or reoperative crura.[3][1][2]
When mesh is required, small onlay or keyhole reinforcement with biologic material is preferred given concerns about long‑term complications (erosion, stricture) seen with permanent synthetics, and randomized data show that early recurrence reduction with biologic mesh may not persist on long‑term follow‑up.[3][1]
Step 9: Creation of the antireflux barrier
Because complete disruption of the phrenoesophageal ligament and extensive mobilization predispose to postoperative reflux, most guidelines and expert series recommend routine fundoplication with paraesophageal hernia repair unless specific contraindications exist. A “floppy” 360° Nissen fundoplication over a 54–56 Fr bougie is common in patients with preserved motility, while partial posterior wraps (Toupet 270° or similar) are selected in the presence of poor motility or high dysphagia risk.[4][5][6][2]
The fundus is brought posteriorly through a retroesophageal window created between esophagus and posterior vagus, and a shoe‑shine maneuver confirms correct orientation without twist before suturing. Sutures secure fundus to esophagus and to the crural pillars, often incorporating the esophageal fat pad to reduce risk of wrap slippage and to anchor the wrap below the diaphragm.[1][2]
Step 10: Gastropexy in selected patients
In patients who present predominantly with obstructive symptoms (volvulus, post‑prandial pain, dysphagia, dyspnea) and minimal reflux, some high‑volume centers now omit formal fundoplication and perform a complete mobilization with primary cruroplasty plus an extended gastropexy. After all the standard steps (sac reduction, mediastinal mobilization, crural repair), horizontal mattress sutures are placed from the gastric fundus and body along the line of the short gastrics to the left hemidiaphragm and sometimes anterior abdominal wall, recreating a physiological angle of His and fixing the stomach below the diaphragm.[2][1]
Multiple sutures, spaced roughly 2 cm apart across 10–14 cm, provide broad adhesion and reduce the risk of re‑herniation or volvulus. This “complete mobilization gastropexy” approach is particularly attractive in elderly or frail patients, where avoiding a wrap may reduce dysphagia and gas‑bloat while still addressing the life‑threatening mechanical component of the hernia.[1][2]
Intraoperative adjuncts and technical pearls
A large‑caliber bougie is used during fundoplication and Collis to calibrate lumen size and help prevent an overly tight wrap or neoesophagus. In challenging redo or giant defects with rigid, immobile crura, deliberately creating a low‑pressure left pneumothorax with a separate 5 mm chest port can relax the diaphragm and facilitate tension‑free crural closure.[1]
Routine intraoperative endoscopy is advocated by some groups to confirm esophageal length, assess wrap position, and detect inadvertent perforation or staple‑line leaks early. Meticulous hemostasis in the mediastinum and hiatus is essential, as small bleeds in a restricted laparoscopic field quickly impair visualization and increase operative time and risk.[2][1]
Postoperative management and follow‑up
Most patients are extubated on table and transferred to recovery; ICU admission is individualized based on age, comorbidity, urgency and operative course. Oral intake typically starts with liquids and advances as tolerated, with emphasis on small, frequent meals and careful chewing in the early weeks to limit dysphagia and bloating.[2]
We perform a contrast swallow (water‑soluble or barium) before discharge or at early follow‑up to document subdiaphragmatic position of the wrap/Collis segment, check for leak and evaluate transit. Long‑term surveillance with periodic symptom assessment and interval barium esophagram (for example at 1 year and then every 2 years) allows early detection of anatomic recurrence, which occurs in about 10–20% radiographically in large series, although reoperation rates are lower (<5–10%) when the above principles are followed.[7][1][2]
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