What Is a Hiatal Hernia Repair?

1. Control respiratory infections. ^[1]

Esophageal hiatal hernia repair

Esophageal hiatal hernia repair is a surgical method used to treat esophageal diseases. It is suitable for the following situations: 1. Symptoms are severe and persistent, and medical treatment fails. 2. Patients with severe reflux esophagitis. 3, bleeding or suspected of malignant changes.

Preparation for esophageal hiatal hernia repair

1. Control respiratory infections. ^[1]

2. Treatment of reflux esophagitis.

3. Correct the nutritional status of the whole body. ^[1]

Position selection and anesthesia method for esophageal hiatal hernia repair

Selection of surgical position for esophageal hiatal hernia repair

Select the right lying position.

Anesthesia method for esophageal hiatal hernia repair

Endotracheal intubation under general anesthesia. ^[1]

Surgical procedure for esophageal hiatal hernia repair

Transesophageal hiatal hernia repair

1. Make a longitudinal incision on the posterolateral or axillary side of the left chest and enter the chest through the 7th or 8th intercostal space.

2. Find a hiatal hernia in the triangular space between the diaphragm, pericardium, and thoracic aorta. Incision of the mediastinal pleura (Figure 1) reveals the hernia sac and the lower end of the esophagus.

Illustration 1: Incision of the mediastinal pleura

Diagram 2: Pull the lower esophageal gauze band

Figure 3: Cut loose sacroesophageal ligaments

3. Pull the lower esophageal gauze band (Figure 2).

4. Cut loose sacroiliac esophageal ligament (Figure 3).

5. Completely free the lower esophagus and the cardia, and isolate the diaphragmatic foot by bluntness (Figure 4).

6. Suture 3 to 4 stitches on both sides of the diaphragm muscle foot (Figure 5), and do not ligate for the time being (Figure 6).

Schematic 4: Free esophagus and cardia, separate diaphragmatic feet

Schematic 5: Intermittent suture on both edges of diaphragmatic foot

Figure 6: The two edges of the diaphragmatic foot are temporarily not ligated

7. Suture the free edge of the sacroesophageal ligament and the diaphragmatic hole in the esophagus (Figure 7).

8. Put the cardia and the lower part of the esophagus back into the abdominal cavity, and ligate the sutures preset on the inner and outer edges of the hole from deep to shallow one by one.

9. Finally ligate the mattress suture in front of the cracked hole (Figure 8).

10. Place closed thoracic drainage and suture the incision layer by layer.

Schematic 7: Suture the free margin of the esophageal ligament and the diaphragmatic hiatus

Figure 8: Mattress suture in front of a ligature

Illustration 9: Hernia sac protruding into the thorax

Transesophageal hernia repair

1. The hernia sac protruding into the thorax can be found on the condyle after entering the chest (Figure 9).

2. Incision of the hernia sac shows abdominal organs such as the stomach, colon, and omentum (Figure 10).

3. Separate the adhesions, return the contents of the hernia to the abdominal cavity, and cut off the excess hernia sac and surrounding fatty tissue (Figure 11).

4. Intermittent suture closure of the hernia sac, mattress suture fixation in the lower esophagus and hiatus (Figure 12).

Diagram 10: Abdominal organs such as stomach, colon, omentum

Schematic 11: Cut off excess hernia sac and adipose tissue

Figure 12: Fixing the lower esophagus and the hole

Esophageal hiatal hernia repair

1. Suture the free gastric bed with vertical mattress sutures on the anterior wall and lateral wall of the lower part of the esophagus for a total of 3 stitches (Figure 13), accounting for about 2/3 of the esophagus circumference.

2. Fold the bottom of the stomach upwards and suturing the vertical mattress into the esophagus 3cm above the cardia (Fig. 14), and 5cm away from the edge of the hiatus. fixed.

Figure 13: Sutured gastric fundus

Figure 14: Fold up and suture the bottom of the stomach

Schematic 15: Pass the bottom of the stomach through the diaphragm and pull out from above

Esophageal hiatal hernia repair

1. Make an incision in the middle of the upper abdomen and enter the abdominal cavity.

2. Pull the stomach downward and cut the peritoneum in the front of the lower end of the esophagus.

3, blunt dissection of the esophageal ligament.

4. Pull the esophagus to the upper left with a gauze band.

5. Suture 3 to 4 stitches of the inner and outer edges of the lame foot from the bottom of the esophagus.

6. Carefully test whether the tightness of the esophageal hiatus after suture is moderate. The standard is the same as "transthoracic repair".

7. Intermittently suture the lower part of the esophagus and the iliac esophagus ligament, and fix it with the esophageal hiatus.

8. Suture the abdominal incision layer by layer. ^[1-2]

Laparoscopic fundoplication of esophageal hiatal hernia repair

General anesthesia intubation. The patient took a supine lower extremity abduction position with the head and feet low 30 & ordm; the surgeon stood between the patients' legs. Pneumoperitoneum was established with a pressure of 12-15mmHg. Generally need to pierce two 1.0cm and three 0.5cm holes in the upper abdomen to place a trocar of the corresponding size. The first 1.0cm hole is located at the junction of the middle and lower 1/3 of the umbilicus and the xiphoid process, and 30 & ordm; endoscope is placed; the second 1.0cm hole is located 2cm below the left clavicle midline costal margin, and is the main operation hole. And other main operating instruments; the first 0.5cm hole is located under the anterior line of the left axillary line and is used by assistants such as non-injury grasping forceps; the second 0.5cm hole is located under the costal line of the right clavicle. , Put the grasping forceps or separating forceps; the third 0.5cm hole is located under the xiphoid process, put Babcock forceps (babcock) forceps to grasp the fascia above the esophageal hiatus to open the liver and expose the hiatus. Those with esophageal hiatal hernia first reset the contents of the hernia, and use an ultrasonic knife to segment the omentum tissue and short gastric blood vessels between the gastric fundus and the spleen segment by segment, freely cut the gastric and esophageal ligaments, expose the left diaphragmatic foot, and use ultrasound The knife cuts off the omentum of the small curved side of the stomach, freeing the right diaphragmatic foot and the peritoneum in front of the esophagus; freeing the length of the esophagus 5cm to create a posterior esophageal space. Use 2-0 silk sutures to intermittently suture the diaphragm muscles on both sides to reduce the esophageal hiatus. If the diameter of the hiatus is larger than 5cm, you can use patches to repair. Pull the bottom of the stomach through the esophagus to the front of the esophagus, and suture the gastric wall on the left side of the esophagus (intermittent suture with 2-0 silk suture 2 ~ 3 stitches, about 1.5 ~ 2.0cm wide, at least two stitches must be sewn to the esophagus muscle layer), Form a 360 ° loose fold (Nissen fundoplication), tension-free around the lower part of the esophagus. If it is a Toupet gastric fundus fold, the gastric tissues on both sides of the esophagus are sutured and fixed to the side wall of the esophagus respectively to form a partial gastric fundus fold of 180 ° to 270 °.