What are the steps for laparoscopic repair of a paraesophageal hernia (PEH)?

From the Guidelines

Laparoscopic paraesophageal hernia repair should be performed with a minimally invasive abdominal approach, utilizing a mesh to reinforce the crural defect closure, and a fundoplication to manage gastroesophageal reflux, as this approach has been shown to have an excellent safety profile with a reported overall in-hospital mortality rate of 0.14% 1. The procedure involves several key steps, including patient positioning, placement of ports, establishment of pneumoperitoneum, and identification of the hernia.

• The hernia contents are reduced back into the abdominal cavity by careful dissection of adhesions.
• The hernia sac is completely excised from the mediastinum and the esophagus is mobilized to ensure adequate intra-abdominal length (at least 2-3 cm).
• The crural defect is closed primarily with non-absorbable sutures, and a mesh (biologic or synthetic) is used to reinforce the repair, with the mesh overlapping the defect edge by 1.5–2.5 cm 1.
• A fundoplication is then performed, with Nissen (360-degree) being most common, though Toupet (270-degree) may be used in certain cases, and the fundoplication should be loose and short (2-3 cm) 1. The use of a mesh and fundoplication has been shown to reduce recurrence rates and manage gastroesophageal reflux, which is a common complication of paraesophageal hernia repair, with an incidence of up to 62% 1.
• The choice of surgical approach and technique should be tailored to the individual patient, taking into account factors such as the history of gastroesophageal reflux, the need to repair a large defect, and the presence of a congenital hernia 1.
• A Collis procedure or gastric resection may be required in selected cases, determined by the gastric condition, and gastropexy may be performed to anchor the stomach to the abdominal wall and prevent recurrence 1.

From the Research

Steps for Laparoscopic Paraesophageal Hernia Repair

The following steps are involved in laparoscopic paraesophageal hernia repair:

• Complete reduction of the hernia sac from the mediastinum back into the abdomen with careful preservation of the integrity of muscle and peritoneal lining of the crura 2
• Aggressive and complete mobilization of the esophagus to the level of the inferior pulmonary vein 2
• Vagal preservation 2
• Clear identification of the gastroesophageal junction to allow accurate assessment of the intraabdominal esophageal length 2
• Use of Collis gastroplasty when esophageal lengthening is required for a tension-free intraabdominal repair 2
• Liberal mobilization of the phrenosplenic and phrenogastric attachments to substantially increase the mobility of the left limb of the crura, allowing for a tension-free primary closure in a large percentage of patients 2
• Crural repair and fundoplication (e.g., Nissen or Toupet procedure) to construct an adequate antireflux barrier 3, 4

Preoperative Evaluation

Preoperative evaluation includes:

• History and physical examination 5
• Upper endoscopy 5
• Radiographic evaluation of the paraesophageal hernia (e.g., barium esophagram, computed tomography scan) 5
• Further testing (e.g., esophageal manometry, 24-hour pH monitoring) directed by patient symptoms, especially in the case of discordance between symptoms and imaging findings 5

Operative Technique

The operative technique involves:

• Hernia reduction 4
• Crural repair 4
• Fundoplication (e.g., Nissen or Toupet procedure) 4
• Construction of an adequate antireflux barrier (e.g., fundoplication) 3