Esophageal Lengthening in Paraesophageal Hernia Repair

This video discusses when and how to perform esophageal lengthening in paraesophageal hernia repair. Determination of intraabdominal esophageal length is a key step in a paraesophageal hernia repair. Ideally, 2.5-3 cm of intraabdominal esophageal length is desired after mediastinal mobilization. A short intraabdominal esophageal length contributes to hernia recurrence. 

There are several predictive factors for requiring an esophageal lengthening procedure. These include a longstanding history of reflux, failed anti-reflux operations, the presence of stricture, and a type III or type IV hernia. Some studies have shown esophageal length of less than the fifth percentile on manometry or an esophageal length index of less than 19.5 to be predictive. Despite these predictive factors, the true standard for determining intraabdominal esophageal length is an intraoperative diagnosis. 

The Surgery

In this procedure, the hernia was reduced in the abdomen after the excision of the hernia sac. Mediastinal mobilization of the esophagus was performed up to the inferior pulmonary vein and the GEJ fat pad was removed. All traction on the esophagus was then released and the NG tube was pulled back. 

Next, the intraabdominal length was measured by the distance from the GEJ to the anterior crus either using an instrument or the aid of endoscopy to locate the Z line. Ongoing mediastinal esophageal mobilization was completed up until the inferior pulmonary vein and the aorta could be seen to the right. Upon completion, the penrose drain was loosened and the GEJ was identified at the level of the hiatus. 

Subsequently, a lengthening procedure was planned. There are multiple ways of performing an esophageal lengthening during a laparoscopic hiatal hernia repair. A modified Collis gastroplasty is demonstrated in this video using an EEA stapler to make a circular opening approximately 6 cm from the GEJ. This was followed by the firing of the Endo GIA stapler. Surgeons employ this method during an open procedure, but for minimally invasive procedures the preference is either the wedge gastroplasty or left transthoracic stapling approach, which is also demonstrated in this video. The right transthoracic stapling approach is similar to the left transthoracic stapling method.

To complete the wedge gastroplasty, an Endo GIA stapler was introduced through the left-sided port and advanced until the tip was adjacent to the bougie. Inferior traction on the stomach is very important to avoid a 90-degree angle to the bougie, which can result in an unnecessarily large wedge and can make the subsequent fundoplication difficult. Next, the stapler was fired. Generally, another load is required to ensure the staple line extends up to the bougie. Subsequently, the tip of the wedge was grasped and the stapler was positioned parallel and snug against the bougie. This maneuver is important to prevent redundancy of the neoesophagus. The second firing of the stapler completed the wedge, which was then retrieved in an endocatch bag.

The left transthoracic stapling approach requires preoperative lung isolation with a double lumen endotracheal tube and the patient positioned with the left side bumped slightly. During this procedure, the camera was manuevered into the left hemithorax after the pleura was opened. A port was inserted under direct visualization in the seventh or eighth intercostal space in the posterior axillary line. An Endo GIA stapler was inserted, reticulated maximally, and positioned parallel and adjacent to the bougie. The penrose drain was then removed. 

Lateral retraction on the greater curve of the stomach aids in positioning the stapler snugly against the 50 Fr bougie to prevent redundancy of the neoesophagus. It is important to ensure that the posterior limb of the stapler does not injure the posterior wall of the stomach. Careful positioning of the stapler ensures a staple line that is parallel and abutting the bougie. Generally, two stapler loads are used with a target of 6 cm of esophageal lengthening.

Comparing the two techniques, there are pros and cons with each approach. The wedge gastroplasty can be completed using the standard ports for paraesophageal hernia repair. However, resecting a large wedge can make fundoplication difficult. This is especially relevant when the patient has a small fundus. In addition, the neoesophagus can become redundant if the first staple load does not abut the bougie. Some surgeons use smaller bougies, such as 40-45 Fr, to circumvent this problem. The left transthoracic stapling is more technically demanding with a higher learning curve. It requires lung isolation and a transthoracic port. However, its major advantage is that there is no resection of the stomach and decreased risk of a redundant neoesophagus.

References

1. Horvath, Karen D. MD*; Swanstrom, Lee L. MD†; Jobe, Blair A. MD†. The Short Esophagus: Pathophysiology, Incidence, Presentation, and Treatment in the Era of Laparoscopic Antireflux Surgery. Annals of Surgery. 232(5):p 630-640, November 2000.
2. Reinersman JM, Deb SJ. Transthoracic Paraesophageal Hernia Repair. Thorac Surg Clin. 2019 Nov;29(4):437-446. doi: 10.1016/j.thorsurg.2019.07.001. PMID: 31564401.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.