Giant Hiatal Hernia Repair Left Triangular Ligament Anterior Hiatoplasty

1. Giant Hiatal Hernia RepairLeft Triangular Ligament Anterior Hiatoplasty Dr. Karem Batniji Department of Surgery , SMC Dr Karem Batniji Department Of Surgery, SMC

2. INTRODUCTION • A giant hiatal hernia (HH) is a hernia that includes at least 30% of the stomach in the chest, most commonly, a giant HH is a type III - IV hernia. • However; Abbreviated descriptions of hiatal hernia such as HH I-IV do not influence the choice of operative technique to be used. • Perfected classification: (O Ospanov et al. 2011 ) • Width (W): most important; W1 < 3 cm; W2, 3-5 cm; W3, 5-8 cm; and W4 > 8 cm. • Length (L): L1 < 5 cm; L2, 5-8 cm; and L3 ≥ 8 cm. • Grade of short esophagus (SE): with SE0, no shortening; SE1, shortening by ≤ 4 cm; and SE2, shortening by > 4 cm. • Hiatal hernia recurrence (R): R0, no recurrence and R (n), the number of previous hernia repairs. Dr Karem Batniji Department Of Surgery, SMC

3. BACKGROUND • Tension-free closure of the esophageal hiatus is a key step to laparoscopic hiatal hernia repair. • Usually, this is achieved with simple interrupted sutures (i.e., posterior hiatoplasty). • However, non-compliant crura / elevated radial tension at the hiatus  primary closure may be impossible or ONLY achievable under significant tension. • Closure under tension significantly contributes to recurrence, (>50 %). Dr Karem Batniji Department Of Surgery, SMC

4. BACKGROUND • When faced with a difficult diaphragmatic closure, surgeons have several options: • Use mesh or an autologous tissue flap (e.g., falciformligament, teres ligament). • Pleurotomy(intentional pneumothorax) or diaphragmatic (crural) relaxing incisions. • Perform a gastropexy without closure of the hiatus. • These techniques appear to be safe. • However, long-term ability to prevent recurrent hiatal hernia has not been fully assessed yet. Dr Karem Batniji Department Of Surgery, SMC

5. PATIENT DESCRIPTION • A 60 y/o lady • Long standing dyspnea on effort, chest pain, GERD and upper abdominal fullness. • Hx hypothyroidism and hypertension (controlled). • Hx abdominal hysterectomy 1 year earlier. • PE unremarkable. • Lab. Tests: within normal. • EGD (report) : big hiatal hernia. • Swallow study (report) : huge HH. • CT scan: Dr Karem Batniji Department Of Surgery, SMC

6. PATIENT DESCRIPTION Dr Karem Batniji Department Of Surgery, SMC

7. PATIENT DESCRIPTION Dr Karem Batniji Department Of Surgery, SMC

8. INTERVENTION • Preoperative: optimization, Anesthesia, patient counselling. • GA, modified lithotomy, laparoscopic approach. • Gigantic hiatus, GE junction, stomach/colon and omentum in the chest. • Sac dissected (ant./post.) then excised. • Crural dissection, non-compliant and widely separated. • Esophagus mobilized to adequate intra abd. portion. • Posterior cruroplasty performed to the extent possible • 360⁰ wrap performed. • Anterior hiatal defect closed by tension free suture darning. • Lt ∆ lig. Mobilized over the ant hiatus, fixed to the crura. • Gastropexy done. Dr Karem Batniji Department Of Surgery, SMC

9. INTERVENTION Dr Karem Batniji Department Of Surgery, SMC

10. RESPONSE TO TREATMENT • Smooth postoperative course. • NG tube removed on day 2 , sips of water allowed. • Day 3: Tube drain removed , patient discharged. • OPD (1wk, 4 wk, 14 m) : No clinical evidence of recurrence. Dr Karem Batniji Department Of Surgery, SMC

11. LITERATURE Dr Karem Batniji Department Of Surgery, SMC

12. DISCUSSION • A successful repair of giant HH requires: • Adherence to basic hernia repair principles (ie, hernia sac excision, tension-free repair), • Recognition and correction of a short esophagus, • Well-performed anti-reflux procedure. • Lt ∆ ligament repair is possible and probably safe. • Further studies to validate the long term results are needed. Dr Karem Batniji Department Of Surgery, SMC

13. REFERENCES • Aye, R. W., & Hunter, J. G. (2016). Fundoplication Surgery. Springer International Publishing:.‏ • Ghanem, O., Doyle, C., Sebastian, R., & Park, A. (2015). New surgical approach for giant paraesophageal hernia repair: closure of the esophageal hiatus anteriorly using the left triangular ligament. Digestive surgery, 32(2), 124-128.‏ • Scott-Conner, C. E. (2013). Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. Lippincott Williams & Wilkins.‏ • Louie, B. E., Blitz, M., Farivar, A. S., Orlina, J., & Aye, R. W. (2011). Repair of symptomatic giant paraesophageal hernias in elderly (> 70 years) patients results in improved quality of life. Journal of Gastrointestinal Surgery, 15(3), 389-396.‏ • Aly, A., Munt, J., Jamieson, G. G., Ludemann, R., Devitt, P. G., & Watson, D. I. (2005). Laparoscopic repair of large hiatal hernias. British journal of surgery, 92(5), 648-653.‏ • O Ospanov, R Khasenov, I Volchkova. Intraoperative Measurement, Classification, And Abbreviated Description Of Hiatal Hernias. The Internet Journal of Surgery. 2010 Volume 27 Number 1 Dr Karem Batniji Department Of Surgery, SMC

14. THANK YOU Dr Karem Batniji Department Of Surgery, SMC