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
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 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