Paraesophageal Hernia Repair
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Transcript Paraesophageal Hernia Repair
Morgan Randall
Paraesophageal Hernia
Indications
Patients with a PEH will present with:
Gastroesophageal Reflux Disease (GERD)
Dysphagia
Epigastric Pain
Vomiting
Barrett’s Epithelium
Postprandial Fullness or Pain
Pulmonary Dysfunction
Preoperative Tests
Chest X-Ray
Barium Esophagram
Esophagogastroduodenoscopy
Esophageal pH Study
CT Scan (rare)
MRI (rare)
Pulmonary Function Test (rare)
Classification
Type I
not considered a true PEH
Upward migration of the GE junction into the
mediastinum
Hernia sac consists of visceral peritoneum,
paraesophageal membrane, anterior wall of gastric
cardia
Type II
Upward dislocation of fundus of stomach alongside a
normally positioned intraabdominal GE junction
Classification cont.
Type III
Upward displacement of both GE junction and gastric
fundus
More common than Type II
Type IV – aka Giant
Contains viscera other than stomach
Laproscopic vs Open
Advantages of Laproscopic Procedure
Quicker Recovery
Decreased Length of Hospital Stay
Quicker Return to Normal Activities
Reduced Recurrence Rate
Fewer Infections
Smaller Incisions
Advantages of Open
Increased Abdominal Access
Contraindications
Contraindications for the laparoscopic approach
Absolute contraindications:
abdominal or mediastinal perforation.
Relative contraindications
single or multiple recurrences in patients with multiple
abdominal scars (the thoracic route may be indicated in
these patients),
Instruments Used
Scalpel
Penrose Drain
Syringe
56 French Bougie
5mm, 10mm, 12mm
Suction/Irrigation System
Trocars
30° Laproscope
Liver Retractor
Harmonic Scalpel
Atraumatic Graspers
Articulating Grasper
Endo Universal 65 Stapler
Bioilogic Implant Mesh
Suture
0 Braided Silk
2-0 Braided Silk
Room Setup
Port Placement
Port Placement
10mm Port
15 cm
5mm Port
5mm Port
12mm Port
Room Setup
Place Liver Retractor
Important Structures
http://upload.wikimedia.org/wikipedia/commons/4/4b/Gray793.png
http://www.biology-online.org/articles/computer_simulation_analysis_normal/figures.html
http://www.med.umich.edu/anatomy/plastinate/galleries/Green_Lab/Abdominal_Cross_Section.html
Hernia Dissection
Mobilize Fundus of Stomach
Place Penrose Drain
Hernia
Stitch Hernia Closed
Stitch Hernia Closed
Add Mesh and Staple in Place
Nissen Fundoplication
Endoscopy to Check Alignment
Questions?
Thank You
Refrences
Special Thanks to Dr. John Roth
Benign Esophageal Disease. Thoracic Surgery. Stanford School of Medicine.
http://thoracicsurgery.stanford.edu/patient_care/benign_esophageal.html
Pierre, Andrew F. and Luketich, James D. Laproscopic Repair of Giant
Paraesophageal Hernias. Cardiothoracic Surgery Network.
http://www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-9.html
Paraesophagel Hernia. Mount Sinai School of Medicine.
http://www.mssurg.net/Team5Conferences/Paraesophageal%20Hernia%202.pdf
Laparoscopic Paraesophageal Hernia. Ohio State University Center for
Minimally Invasive Surgery. The Ohio State University. Department of Surgery.
http://cmis.osu.edu/8818.cfm
www.websurg.com
UK HealthCare. Hernia Facts Sheet.
http://www.ukhealthcare.uky.edu/publications/healthfocus/fact_sheets/herni
as.asp
Endo Universal 65
RETURN
http://www.covidien.com/hernia/us/fixation/endouniversal
30° Endoscope
RETURN
http://www.stryker.com/en-us/products/Endoscopy/Laparoscopy/Laparoscopes/StandardLengthLaparoscopes/index.htm
Trocar
Available in 5mm, 8mm, 10mm, 12mm
RETURN
http://www.ethiconendosurgery.com/Clinician/Product/access/trocars/xcelbladeless#About
Biologic Implant Mesh
RETURN
http://www.covidien.com/hernia/us/biologics/permacol
Maryland Dissector
RETURN
http://www.ethiconendosurgery.com/Clinician/Product/endodevices/endohandinstruments#description-specs
Penrose Drain
RETURN
http://www.covidien.com/criticalcare/pageBuilder.aspx?webPageID=0&topicID=67861&xsl=xsl/productPagePrint.xsl
56 French Bougie
RETURN
http://www.stryker.com/en-us/products/Endoscopy/Laparoscopy/AccessoriesandDisposables/InfraVisionEsophagealKit/index.htm
Articulating Grasper
RETURN
http://www.covidien.com/autosuture/pagebuilder.aspx?topicID=195028&breadcrumbs=0:63659,172308:0,195057:0
Suction/Irrigation System
RETURN
http://www.endotek.com.tr/default.asp?L=EN&mid=173&cat_id=216
Scalpel
RETURN
http://www.google.com/search?hl=en&sugexp=ldymls&xhr=t&q=scalpel&cp=6&bav=on.2,or.r_gc.r_pw.&wrapid=tljp1303234486536010&um=1&ie
=UTF-8&tbm=isch&source=og&sa=N&tab=wi&biw=1259&bih=617
Harmonic Scalpel
RETURN
http://www.ethiconendosurgery.com/Clinician/Product/energy
http://www.hhsurgical.com/Products/Product/Electrosurgical-Units/NoSub/1445-Ethicon-G110-Harmonic-Scalpel-.chtml
Syringe
RETURN
http://www.mediray.com/Pages/Products/SyringeShields.html
Liver Retractor
RETURN
http://www.bristolsurgery.com/article.aspx?articleid=100749
Suture
RETURN
http://www.syneture.com/syneture/pageBuilder.aspx?topicID=315
http://www.sosmedicalsuperstore.com/PhotoGallery.asp?ProductCode=A306H