Laparoscopic Repair of Paraesophageal Hernia

Parasesophageal hernias are the rarest diaphragmatic hernias in children. This video demonstrates the repair of a very large type 3 hiatal hernia. The patient is an 18 month old, otherwise healthy girl. A chest X-ray done for a suspicion of a swallowed foreign body revealed the right thoracic mass seen here. Her parents reported her to have a poor appetite but no other GI or respiratory symptoms. A CT scan of the chest and upper abdomen revealed a large postremedial diaphragmatic hernia containing a dilated, redundant stomach. A laparoscopic procedure was performed. The steps were exposure of the defect, excision of the sac, reduction of the viscera, repair of the hernia, and fundoplication. The locations of 55 millimeter trocars are shown. The surgeon and assistant are at the foot of the patient. The large defect is easily seen with the hernia containing the omentum and a large portion of the stomach. Exposure of the defect is maintained by a grasper on the diaphragm introduced through an epigastric trochar. Dissection of the sac is necessary in order to reduce the viscera and visualize the full defect. This starts with sharp dissection of the sac off the right diaphragmatic cruise. The sac is seen tethering the stomach in the mediastinum. The right cruise of the hiatus is grabbed and retracted medially. Sharp dissection continues to separate the sack from the right cruise. A similar dissection is carried out at the left cruise. Separation of the sack from the cruise is carried out by sharp dissection. The cruise is progressively better defined as the sac is separated. The left visceral pleura is clearly visualized. Mobilization of the gastroesophageal junction begins by blunt dissection posteriorly. And anteriorly. The gastric cardia is still tethered to the mediastinum. This can be seen from the left side as well. The aorta is clearly visible in this view. In order to completely mobilize the cardia and fundus, the superior short gastric vessels are divided. This will also aid with the fund duplication further in the case. Once the stomach is completely freed from the spleen, the posterior attachments of the stomach to the hiatus are also divided. The proximal stomach has been fully mobilized intraabdominally. Downward traction on the stomach allows for aversion of the sac from the mediastinum. And facilitates its removal. The posterior vagus nerve is clearly seen in this view. Excision of the sac continues. This will facilitate complete reduction of the GE junction and stomach. The sack is now completely excised. This has been a tedious task but will greatly facilitate the remainder of the procedure. The hiatus is repaired with interrupted 2-0 braided non-absorbable suture. The anteriormost suture is placed first to minimize tension. A second suture is placed anterior to the esophagus. The posterior defect is now visualized. Note that complete reduction, including a good segment of the esophagus, has been accomplished. The posterior defect is also closed with two interrupted stitches. Taking care not to constrict the esophagus. A suture has been placed between the esophagus and the right cruise to decrease the chance of recurrence. A similar suture is now being placed between the left cruise and the esophagus. A 360 degree floppy funduplication completes the procedure. The most challenging part of this procedure was complete excision of the redundant adherent sac and total reduction of the distal esophagus, gastroesophageal junction, and stomach. The remainder of the procedure much resembled a routine Nissen fundoplication. The final result is seen. The patient was started on oral intake the next day and discharged on the 3rd postoperative day. Her postoperative chest X-rays, 2 weeks and 4 months after the repair are shown. At 4 month follow up, she was thriving with a good appetite. Her weight had improved from the 20th to the 50th percentile.