From the Guidelines
A paraesophageal hernia repair with Nissen fundoplication involves several key steps, including reduction of the hernia, dissection and excision of the hernia sac, mobilization of the esophagus, closure of the crural defect, and creation of a tension-free wrap around the distal esophagus. The procedure typically begins with the patient in reverse Trendelenburg position and access gained to the abdominal cavity via a laparoscopic approach using 5 ports 1. The hernia is reduced by carefully pulling the stomach and other herniated contents back into the abdominal cavity. The hernia sac is then dissected from the mediastinum and excised. Next, the esophagus is mobilized to ensure adequate intra-abdominal length (at least 2-3 cm) to prevent recurrence. The crural defect is closed using non-absorbable sutures, typically in a posterior-to-anterior direction. For large defects, mesh reinforcement may be necessary, with the mesh overlapping the defect edge by 1.5–2.5 cm 1.
The Nissen fundoplication follows, which involves wrapping the gastric fundus 360 degrees around the distal esophagus. This is done by creating a tension-free wrap using 2-3 non-absorbable sutures, ensuring the wrap is 1.5-2 cm in length and properly oriented. A bougie (typically 52-60 French) is often placed in the esophagus during this step to prevent an overly tight wrap. The procedure concludes with testing the wrap integrity and ensuring no tension on the repair. Key considerations include:
- The use of a minimally invasive abdominal approach, which can be performed with an excellent safety profile and a reported overall in-hospital mortality rate of 0.14% 1
- The potential need for a combined or thoracic approach in right diaphragmatic hernia due to the presence of the liver 1
- The high incidence of gastroesophageal reflux after repair of congenital diaphragmatic hernia, making fundoplication an important consideration 1
- The selection of surgical procedure based on factors such as history of gastroesophageal reflux, need to repair a large defect, presence of a paraesophageal hernia, or congenital hernia 1.
Postoperatively, patients typically follow a graduated diet starting with liquids and progressing to soft foods over 2-4 weeks to allow healing and minimize stress on the repair. This procedure effectively treats both the anatomical defect of the hernia and the functional issue of gastroesophageal reflux by restoring normal anatomy and creating a one-way valve mechanism at the gastroesophageal junction.
From the Research
Steps Involved in Paraesophageal Hernia Repair and Nissen Fundoplication
The steps involved in paraesophageal hernia repair and Nissen fundoplication include:
- Reduction of the hernia: This involves reducing the stomach back into the abdomen 2, 3
- Excision of the sac: The hernia sac is resected to prevent further herniation 2, 3
- Crural approximation: The crura of the diaphragm are approximated to close the defect 2, 3
- Fundoplication: A Nissen fundoplication is performed to "pexy" the stomach within the abdomen and control postoperative reflux 2, 3
- Gastropexy: Some studies suggest the use of gastropexy as an alternative to fundoplication 4
Key Considerations
- The approach to repair of paraesophageal hernias is controversial, with some studies suggesting the use of mesh repair and others advocating for a non-mesh approach 5
- Routine fundoplication during PEH repair has been favored despite significant dysphagia rates 5
- A tailored approach to incorporation of fundoplication during PEH repair may be necessary, with some patients requiring pharmacotherapy alone for reflux symptoms 4
Surgical Approach
- Laparoscopic repair of paraesophageal hernias is a viable alternative to open surgical approaches, with shorter hospitalization and return to full activity 2, 3
- The use of laparoscopic access with traditional surgical technique has been shown to be effective in treating patients with complex paraesophageal hernias 3