What are the surgical steps in Video-Assisted Thoracic Surgery (VATS) paraesophageal hernia repair?

Surgical Steps in VATS Paraesophageal Hernia Repair

The surgical approach for VATS paraesophageal hernia repair should combine thoracoscopic and laparoscopic techniques to ensure complete mobilization of the hernia sac, reduction of herniated contents, and secure repair of the diaphragmatic defect.

Patient Positioning and Port Placement

• Position patient in lateral decubitus position for VATS portion
• Standard VATS port placement (typically 3-4 ports)
• After thoracic portion, reposition for laparoscopic approach with patient supine

Thoracic Phase (VATS)

1. Initial Assessment:

   • Evaluate extent of hernia and associated pathology
   • Identify anatomical landmarks (aorta, pericardium, mediastinal pleura)

2. Hernia Sac Dissection:

   • Dissect hernia sac posteriorly from thoracic aorta
   • Dissect inferiorly from diaphragmatic attachments
   • Dissect anteriorly from pericardium
   • Dissect laterally from mediastinal pleura 1

3. Esophageal Mobilization:

   • Completely mobilize esophagus up to aortic arch
   • Release anterior vagus nerve from bronchial branches
   • Ensure adequate intra-abdominal esophageal length 1

4. Hernia Sac Management:

   • Open the hernia sac
   • Completely dissect and remove the sac
   • Reduce hernia contents into abdomen 1

Abdominal Phase (Laparoscopic)

1. Content Reduction:

   • Reduce stomach and other herniated organs into abdomen
   • Divide short gastric vessels
   • Completely mobilize gastric fundus 1

2. Crural Repair:

   • Close hiatus with interrupted non-absorbable sutures
   • For defects larger than 8 cm or area >20 cm², consider mesh reinforcement
   • If using mesh, ensure 1.5-2.5 cm overlap of defect edge 2

3. Fundoplication:

   • Perform floppy Nissen or partial fundoplication for reflux control
   • Consider Toupet fundoplication as an alternative (may have lower recurrence rates) 2

4. Gastropexy:

   • Perform gastropexy to prevent recurrence
   • Particularly important in cases with gastric volvulus 2

Technical Considerations

• Ensure tension-free primary closure of diaphragmatic defect
• For large defects, consider biological or biosynthetic mesh in clean-contaminated fields 2
• Avoid using tackers near the pericardium due to risk of cardiac complications 2
• If gastric volvulus is present, perform gastropexy after detorsion 2

Potential Complications and Pitfalls

• Inadequate esophageal mobilization leading to tension on repair
• Incomplete hernia sac removal increasing recurrence risk
• Damage to vagus nerves during dissection
• Gastric perforation during mobilization
• Postoperative pulmonary complications including atelectasis 2
• Recurrence rates of 5-7% have been reported with minimally invasive approaches 3

Postoperative Management

• Early mobilization to prevent atelectasis
• Gradual diet advancement
• Consider barium esophagram before discharge to confirm reduction
• Follow-up at 2-4 weeks to assess for early complications

The combined VATS/laparoscopic approach offers excellent visualization of the mediastinum for thorough dissection while preserving the benefits of minimally invasive surgery, resulting in shorter hospital stays and faster recovery compared to open approaches 1.