Nathan S Rubalcava, MD
nathanru@med.umich.edu
@NateRubalcava
@JamesDGeiger
Nathan S Rubalcava, MD; Gabriella A Norwitz; James D Geiger, MD; University of Michigan
Introduction: Repair of large hiatal hernias require adequate intra-abdominal esophageal length for best long-term outcomes and less rate of recurrence. When unable to attain this length without tension, the Collis gastroplasty is an invaluable technique.
Materials and Methods: After placement of the standard 5 laparoscopic trocars for hiatal hernia repair, use of an intra-thoracically placed 45-mm stapler allows for ideal articulation though the hiatus for ligation of the fundus and creation of the neo-esophagus. Bougie placement prior is critical to protect diameter of the esophagus
Results and Conclusion: We describe the use of a laparoscopic Collis gastroplasty with Nissen fundoplication in a 14-month-old who was diagnosed with a large right-sided hiatal hernia with the gastroesophageal junction in the subcarinal position.This is an ideal technique when the gastroesophageal junction cannot be brought below the diaphragmatic hiatus without tension.
Intended audience: Healthcare professionals and clinicians.
This is a case describing laparoscopic hiatal hernia repair, collus gastroplasty, and Nissen fundoplication with gastrostomy tube placement in a 14 month old. A 7.8 kg male presented with constipation, abdominal bloating, and failure to thrive. After control of the constipation and abdominal bloating, a preoperative upper GI study demonstrated a large right-sided hiatal hernia with a gastroesophageal junction in the subcrinal position. We began by placing 55 millimeter trochars and reduced the hiatal hernia contents into the abdomen. We retracted the stomach caudally and dissected the hernia sac completely to delineate the left and right diaphragmatic cura. The vagus nerve was visualized and avoided. We continued to free the thoracic esophagus to gain more intraabdominal length. The hernia sac was completely excised and was removed from the abdomen. A posterior window was created to bring the fundus around as the Nissen fundoplication was being created. With tension on the stomach, we were able to achieve some intraabdominal esophagus. However, the GE junction retracted back into the chest once traction was released. Therefore, we elected to perform a collus gastroplasty. We first passed a 36 French bougie to protect the diameter of the esophagus. Entry into the left chest was gained. At the level of the fourth rib space, given there was no previous thoracic surgery, we passed a 45 millimeter stapler tan load from the chest along the left diaphragm. Using laparoscopic assistance, the stapler was guided through the hiatus. The jaws were then articulated to divide part of the fundus and thus increasing the length of the intraabdominal esophagus, allowing for a tension-free repair. The chest and skin were then closed in layers. You can see the added length obtained that will serve as our neoesophagus. Next, we perform the hiatal hernia repair primarily by closing the posterior hiatus with two figure of eight stitches using 20 silk on a BB needle. The anterior hiatus was closed partially with a single stitch. A Debeki grasper was easily passed both anterior and posterior to the esophagus and into the hiatus demonstrating the closure was not too tight. We then passed the fundus posterior to the esophagus and began our Nissen fundoplication. This back and forth shoeshine technique demonstrated here allows for the fundus to be ideally situated during placement of the fundoplication. With the bougie still in place, the inferior stitch was placed first at the level of the neo GE junction. A 20 silk was passed from the fundus through the esophagus and back through the fundus, and then tied at the 9 o'clock position. This was repeated for the superior stitch. A 3rd stitch was passed between the two, incorporating only the left and right fundus. The bougie was removed and the laparoscopic gastrostomy was performed via push seling, or technique. Transfascial stitches were used to tack the stomach to the anterior abdominal wall. The hiatal hernia repair and fundoplication were evaluated one last time to ensure that there was no tension due to the gastrostomy. 10 of peep was applied during desinflation of the abdomen to prevent pneumothorax. No chest tube was required. The postoperative course was complicated by intermittent desaturations that resolved spontaneously and urinary retention requiring foley catheterization. Given his failure to thrive, he initially had difficulty feeding postoperatively. Feeds were started via chimney set up and gradually were transitioned to bolus feeding. He was tolerating gull feeds by the time he was discharged on post-op day 7. The upper GI swallow study at 2 weeks revealed no leak, intact wrap, and esophageal clearance with no residual hiatal hernia or reflux. Despite postoperative complications, since discharged, he is tolerating oral feeding, gaining weight, and his condition has drama. ically improved when performing the fundoplication, it is crucial to ensure adequate intraabdominal esophagus is maintained without tension, as this will lead to better long-term outcomes with less recurrence or herniation of the wrap above the diaphragm. We have found the cole gastroplasty is a valuable technique in pediatric patients when the GE junction cannot be brought below the diaphragmatic hiatus without tension.
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