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Hernia1 2007

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Hernia1 2007

  1. 1. Paraesophageal Hiatal Hernia
  2. 2. <ul><li>The esophageal hiatus is formed by the right crus and little or no left crus. </li></ul><ul><li>The phrenoesophageal ligament, which holds the distal esophagus in place is formed by fusion by endothoracic and endoabdominal fascia at the esophageal hiatus. </li></ul>
  3. 3. CLASSIFICATION <ul><li>There are 4 types of hiatal hernias. </li></ul><ul><li>The sliding hernia or type I is the most common. </li></ul>
  4. 4. Type I Hiatal Hernia <ul><li>The E-C junction moves through the hiatus to the visceral mediastinum. </li></ul><ul><li>Increased abdominal pressure( pregnancy, obesity, or vomiting ) and vigorous esophageal contraction may contribute the development of the hernia. </li></ul><ul><li>G-E reflux and esophagitis may occur due to loss of tone of the LES. </li></ul>
  5. 5. Type II Hiatal Hernia <ul><li>It is uncommon. </li></ul><ul><li>The phrenoesophageal membrane is not weakened diffusely but focally. </li></ul><ul><li>The gastric fundus protrudes through the hiatus. </li></ul>
  6. 6. <ul><li>52-1 </li></ul>
  7. 7. Type III Hiatal Hernia <ul><li>It is combined with type I and type II. </li></ul><ul><li>It is frequently present when a type II hiatal hernia have been present for many years. </li></ul>
  8. 8. Type IV Hiatal Hernia <ul><li>It refers hernia of organs other than the stomach. </li></ul><ul><li>The T-colon and the omentum are the most common involved. </li></ul><ul><li>The spleen and the small intestine may be involved. </li></ul>
  9. 9. ANATOMY AND PHYSIOLOGY <ul><li>In a true paraesophageal hiatal hernia, the lower esophagus and the cardia remain fixed below the diaphragm in the posterior aspect of the diaphragmatic hiatus. </li></ul><ul><li>The herniated organs are covered with a layer of the peritoneum that forms a true hernia sac, unlike the type I hiatal hernia, in which the stomach forms the posterior wall of hernia sac. </li></ul>
  10. 10. ANATOMY AND PHYSIOLOGY <ul><li>Complications are bleeding, incarceration, volvulus, obstruction, strangulation and perforation. </li></ul><ul><li>Gastritis and ulceration have been seen. The ulcer are the result of poor gastric emptying and torsion of the gastric wall. </li></ul>
  11. 11. SYMPTOMS <ul><li>Many type I and type II hernia have few or no symptoms. </li></ul><ul><li>Bleeding results from gastritis and ulcer can induce IDA, resulting in fatigue and exertional dyspnea. </li></ul><ul><li>Postprandial discomfort may occur. The substernal fullness is often mistaken MI. </li></ul>
  12. 12. SYMPTOMS <ul><li>In type II hernia, G-E reflux and true dysphagia is uncommon. </li></ul><ul><li>If vovulus occurs, severe pain and pressure in the chest or epigastic region. </li></ul><ul><li>Fever, hypovolemic shock will be present if volvulus progresses and strangulation occurs. In this situation, mortality rate is 50%. </li></ul>
  13. 13. DIAGNOSIS <ul><li>The diagnosis is suspected first on the CXR. </li></ul><ul><li>The most common finding is retrocardiac bubble with or without air-fluid level. </li></ul><ul><li>In a giant hiatal hernia, the herniated organ may be found in the right thoracic cavity. </li></ul><ul><li>D.D: mediastinal cyst or abscess, dilated obstructed esophagus, as end stage of achalasia. </li></ul>
  14. 14. DIAGNOSIS <ul><li>The barium study of the UGI confirms the diagnosis. </li></ul><ul><li>Endoscopy and esophageal function test can detect the function of LES. </li></ul>
  15. 15. THERAPY <ul><li>There is no accepted medical treatment for hiatal hernia. </li></ul><ul><li>Surgery is indicated to prevent complications. </li></ul><ul><li>In type II hernia, if gastric volvulus or obstruction is present without toxic signs, NG decompression must be performed. The surgery is scheduled. </li></ul>
  16. 16. Operative Approaches <ul><li>The operation or operative approach is controversial. </li></ul><ul><li>The principles of operation is reduction of the hernia, resection of the hernia sac and closure of the defect. </li></ul><ul><li>It is easy to do intrathoracic dissection via thoracotomy. </li></ul><ul><li>However, transthoracic reduction may lead to volvulus of the gastric body. </li></ul>
  17. 17. Operative Approaches <ul><li>Abdominal approach is also suggested. </li></ul><ul><li>Additional procedures can be done, such as gastrotomy, which obviates the NG tube and decreases the risk of recurrent volvulus. </li></ul><ul><li>Abdomional approach is difficult to do in type III hiatal hernia with G-E reflux and a foreshortened esophagus. </li></ul><ul><li>Laparoscopic repair is also advocated. </li></ul>
  18. 18. Should a Antireflux Procedure Be Induced? <ul><li>It is controversial. </li></ul><ul><li>It is indicated in patients with esophagitis by symptoms and endoscopy, with a hypotensive LES( < 10 mmHg ) or positive 24-hour pH monitoring. </li></ul>
  19. 19. Operative Technique: Conventional Abdominal Approach <ul><li>The author prefers abdominal approach via upper midline incision. </li></ul><ul><li>In type II hernia, the E-C junction is still in the abdomen, bounded posteriorly with a fibrous band. It is careful not to take down the attachment. </li></ul><ul><li>Dissection is done on the lower 4 to 8 cm of the esophagus. </li></ul><ul><li>The repair is done with nonabsorbable O sutures. </li></ul>
  20. 20. Operative Technique: Conventional Abdominal Approach <ul><li>Antireflux procedure is done when significant reflux esophagitis is present. </li></ul><ul><li>A loose Nissen fundoplication is suggested by authors. </li></ul><ul><li>If no fundoplication is performed then the stomach can be fixed by two methods: Hill suture plication and Stamm gastrostomy. </li></ul>
  21. 21. Operative Technique: Conventional Abdominal Approach <ul><li>Hill suture plication: 3 interrupted nonabsorbable sutures between lesser curve of the stomach and preaortic fascia </li></ul><ul><li>Stamm gastrostomy: 2 functions </li></ul><ul><li>1. It eliminates the need of NG tube. </li></ul><ul><li>2. It fixes the stomach to the abdominal wall </li></ul><ul><li>and to prevent volvulus. </li></ul>
  22. 22. <ul><li>52-5 </li></ul>
  23. 23. Operative Technique: Laparoscopic Approach
  24. 24. <ul><li>52-6 </li></ul>
  25. 25. Operative Morbidity and Mortality <ul><li>The operative mortality is less than 0.5%. </li></ul><ul><li>If gasric volvulus occurs, the operative mortality is up to 14%. </li></ul><ul><li>Pulmonary complication may be seen in patients with aspiration resulting from volvulus or obstruction. </li></ul><ul><li>Complication of gastric stasis may result from edema of the released gastric segment. </li></ul>
  26. 26. Operative Morbidity and Mortality <ul><li>Other complications include gastric perforation, gastric bleeding, slipped Nissen fundoplication, small bowel obstruction and atelectasis. </li></ul>
  27. 27. RESULTS <ul><li>Long-term results are excellent. </li></ul><ul><li>Simultaneous antireflux procedure is ineffective prophylaxis against recurrent herniation resultant G-E reflux. </li></ul><ul><li>The long-term result after laparoscopic repair is unknown. </li></ul>
  28. 28. Thank You!

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