Abstract
Recurrent paraesophageal hernia repair is challenging both for the surgeon and the patient, both from a surgical and a recovery standpoint. From adhesions to fusing of organs with complete obliteration of planes between the crus/mesh, hernia sac, esophagus, and gastric wall, often the anatomy is extremely distorted. Surgery requires meticulous dissection to avoid an iatrogenic injury and careful evaluation of final repair to avoid yet another recurrence. Herein, we present our technique of a redo paraesophageal hernia repair and some pitfalls associated with it.
Redo foregut surgery can be extremely challenging even for experienced surgeons and requires careful evaluation of symptoms with concomitant pre-set expectations. Failure of paraesophageal hernia repair may occur early or late in the postoperative period. Early failure can be attributed to poor patient selection and/or technical error, while late failures can result from progression of underlying disease. Factors associated with recurrent paraesophageal hernias include failure to recognize a short esophagus, inadequate closure of the crus, and obesity with increasing body-mass index.1,2
Since redo surgeries are extremely challenging and may carry a lower success rate than initial repair,3,4 it is critical to elucidate the cause of failure and conduct thorough workup including a thorough history and reviewing workup performed prior to index surgery to rule out previously undiagnosed or misdiagnosed etiologies. Barium esophagram and repeat endoscopy are performed prior to considering revisional surgery. Finally, CT imaging, esophageal manometry, pH testing, and gastric emptying studies may be done selectively, especially if the clinical picture is suggestive of esophageal dysmotility, pseudoachalasia, or delayed gastric emptying.
During a redo operation for recurrent hernia, the surgeon may identify a shortened esophagus resulting in migration of the wrap, slipped wrap, or inadequate closure of the crural defect. The most common operation for treatment of a recurrent paraesophageal hernia involves complete reduction of the hernia contents and sac followed by a redo fundoplication with or without mesh and/or gastroplasty. Here, a redo paraesophageal hernia repair is demonstrated with conversion of a prior Nissen to a Toupet fundoplication. However, there are other options including a Roux-en-Y esophagojejunostomy or an esophagectomy (these are not discussed here, beyond the scope of this chapter). These surgical options should be considered before taking the patient to the operating room.
Preoperative Preparation and Patient Positioning
For re-do surgeries, it is recommended to be on a liquid diet for longer than usual (at least 24 hours) prior to surgery, followed by nil per os after midnight. All patients must receive prophylactic antibiotics and subcutaneous heparin prior to induction of general anesthesia. The patient is positioned supine on the operating table with bilateral arms abducted. A footboard is placed to allow for steep reverse-Trendelenburg positioning for maximum exposure.
Minimally Invasive Robotic Assisted Approach: Scope Insertion and Trocar Placement
An on-table endoscopy should be performed to assess the location of the gastroesophageal junction (GEJ) and evaluate the integrity of prior wrap. Next, we begin by placing a camera port using either an Optiview (in virgin territory) or a Hassan technique. After CO2 insufflation, a robotic camera is inserted and additional ports are placed under direct visualization. We attempt to use original port scars for trocar placement in order to minimize scarring, but alternate sites may be utilized as per the discretion of the surgeon.
Adhesiolysis and Exposure
Re-operative hiatal surgeries, especially in the setting of a prior implanted mesh, are fraught with complications secondary to adhesions and obliterated planes. After an adequate adhesiolysis around the liver bed and crus, complete reduction of the hernia and its contents are extremely important to avoid a recurrence. Unless the surgeon performing the redo procedure also performed the original operation and is confident about the integrity of the wrap, the prior wrap should be undone. The robotic platform and its associated advantages allow the surgeon to dissect around the crus and mediastinum with precision. The most common injuries that occur during the course of this dissection include injury to the lesser curve of the stomach or the distal esophagus.
The dissection begins by taking down adhesions to the liver and defining the right crus. As the dissection allows, it can be extended anteriorly to the left crus. Any hernia sac, if identified, and its contents are carefully reduced into the abdomen. Dissection is then extended superiorly into the mediastinum with division of adhesive bands in an attempt to free up the hiatus and assess esophageal length. Occasionally, the hernia sac is densely adherent to the pleura, and entry into the pleural space may be necessary. If violation of the pleural space occurs and the patient becomes symptomatic with hypotension or increased airway pressures, placement of a chest tube or a pigtail catheter can be performed while on the table along with reduction in pneumoperitoneum pressure.
Once circumferential dissection of the hiatus is performed, a Penrose is used to retract the esophagus upward and a retroesophageal window is opened and widened bluntly to enter the left side of the abdomen.
Assessment of Esophageal Length
The most critical aspect of redo hernia repair is to ensure adequate intraabdominal esophageal length without any tension, which should ideally be 3 cm in length. If there is inadequate intraabdominal esophageal length, a Collis gastroplasty must be performed. The esophageal lengthening procedure employs a wedge resection of the gastric fundus to allow for lengthening of the esophagus thus allowing the creation of the wrap on the neo-esophagus.
Hiatal Repair
The posterior and anterior crural defects should be evaluated for adequate approximation and integrity of closure. The defect must be re-approximated with nonabsorbable sutures, either in simple interrupted or figure-of-eight fashion. If crural integrity is questionable, the closure must be reinforced with pledgeted sutures or overlay biologic mesh. Relaxing incisions, preferably on the right hemidiaphragm, can also assist with crural tension. In cases of large crural defects, partial anterior crural closure is recommended to avoid kinking of the esophagus.
Revision Fundoplication
Next, the prior wrap should be completely taken down and a posterior window created. The short gastric vessels are divided, and the fundus is mobilized sufficiently to allow for a shoeshine manuever and subsequent creation of the wrap. A shoeshine maneuver should be performed to confirm proper orientation of the fundoplication and division of any and all prior attachments. A partial 270° wrap or loose Nissen should ideally be performed in all cases to prevent any further scarring with complete wraps and secondary pseudoachalasia. If a re-do Nissen is considered given normal manometry in an otherwise healthy young patient, an Endoflip (Medtronic; Dublin, Ireland) can be employed in the operating room to measure lower esophageal sphincter pressures while constructing the wrap.
In the attached video, a fundoplication wrap is created with 6 simple interrupted 2-0 nonabsorbable sutures: 3 at 10 o’clock and 3 at 2 o’clock on the esophagus. Each bite must be full-thickness on the stomach and partial-thickness on the esophagus. A cruropexy of the wrap to each crural limb can also be performed to avoid a recurrence.
Postoperative Care
An esophagram study should be performed on postoperative day #1 or #2 prior to initiation of oral intake to ensure no missed iatrogenic injury for all re-do surgeries. If no defect or extravasation is detected, patients may start a liquid diet and gradually advance to soft diet and regular food over a period of days to weeks.
Follow-Up
Short-term and long-term follow up are both critical to document resolution of symptoms and development of any new symptoms thereof.
Pitfalls of Revisional Fundoplication
During the mediastinal dissection, the surgeon must identify the esophagus and both vagi to avoid any injury. An endoscope is utilized throughout the surgery to intermittently define the anatomy and assess for any iatrogenic visceral injury. If it is not feasible to continue with careful hiatal dissection (especially in cases of redo, redo hernia, or prior mesh implantation resulting in obliterated planes), transabdominal approach should be aborted and a Belsey repair must be considered.
Ten Surgical Steps Summarized
Safe entry into the abdomen—Hassan or Optiview (virgin port site)
After lysis of adhesions, start off with division of any adhesions between the stomach/wrap and the liver bed. Difficult to ascertain vagi nerves.
Define crus and prior wrap. Preserve the peritoneum overlying the crus. If hernia sac was incompletely removed at index surgery, remove the sac to prevent another recurrence.
Divide all circumferential attachments to the anterior crus, liver, as well as posteriorly to undo the wrap and recreate one if needed.
High esohpageal mobilization must be performed to ensure adequate intra-abdominal length. In case of a migrated wrap, assess if Collis gastroplasty is needed.
Simultaneously scope to understand the anatomy and exclude any iatrogenic injuries during the course of the dissection.
Undo the wrap and re-define anatomy. Perform a snug crural repair; may need relaxing incision in diaphragm and/or mesh if defect is too large or the crural integrity is too poor.
Using Endoflip (Medtronic; Dublin, Ireland) or over an endoscope/Bougie, recreate a loose Nissen, convert to a Toupet, or don’t re-do a wrap in cases of pseudoachalasia.
Perform a cruropexy and/or a gastropexy, whatever is needed to avoid another recurrence.
Finally, perform an endoscopy prior to closure.
Footnotes
Authors’ Note
Reprints will not be available from the author.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
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References
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