Overview
Definition:
Hiatal hernia repair with crural reinforcement in sleeve refers to a surgical procedure aimed at correcting a hiatal hernia, a condition where a portion of the stomach protrudes through the diaphragm, and simultaneously reinforcing the diaphragmatic crura (the muscular pillars forming the esophageal hiatus)
The "sleeve" component typically involves a partial fundoplication, such as a Dor or Toupet fundoplication, wrapped around the lower esophagus
Crural reinforcement is a critical adjunct to prevent recurrence by plicating or suturing the crura together, thereby narrowing the hiatus.
Epidemiology:
Hiatal hernias are common, with prevalence increasing with age, affecting an estimated 10-80% of the population depending on diagnostic criteria
Symptomatic hernias requiring surgical intervention are less frequent, with Type II (paraesophageal) hernias carrying a higher risk of complications
Obesity and increased intra-abdominal pressure are significant risk factors.
Clinical Significance:
Symptomatic hiatal hernias can lead to severe gastroesophageal reflux disease (GERD), dysphagia, chest pain, and in the case of paraesophageal hernias, potentially life-threatening complications like gastric volvulus, strangulation, or perforation
Effective surgical repair is crucial for symptom relief, prevention of complications, and improving patient quality of life
Crural reinforcement is vital for long-term repair durability.
Indications
Indications For Surgery:
Persistent and bothersome symptoms of GERD refractory to medical management, including heartburn, regurgitation, and dysphagia
Large or irreducible hiatal hernias, especially paraesophageal hernias with symptoms of gastric outlet obstruction, chest pain, or risk of volvulus
Patients with suspected or confirmed complications such as bleeding, obstruction, or strangulation
Severe esophagitis or Barrett's esophagus related to reflux
Incidental discovery of large paraesophageal hernias during investigations for other conditions, particularly in younger or healthier individuals where risk of future complications is significant.
Contraindications:
Severe comorbidities rendering the patient unfit for major surgery
Untreated severe peptic ulcer disease
Uncontrolled coagulopathy
Patient refusal or lack of understanding of the procedure and potential risks
Presence of achalasia or other primary esophageal motility disorders that may be exacerbated by fundoplication
Significant active infection.
Preoperative Preparation
Patient Evaluation:
Comprehensive history focusing on reflux symptoms, dysphagia, chest pain, and previous abdominal surgeries
Physical examination to assess for abdominal distension, masses, and hernias
Baseline laboratory investigations including complete blood count, electrolytes, renal and liver function tests, coagulation profile, and ECG
Chest X-ray to assess for any pulmonary pathology or large hernias
Upper endoscopy to assess the extent of esophagitis, presence of Barrett's esophagus, and rule out other upper GI pathology.
Diagnostic Imaging:
Barium swallow or esophagogram is crucial to confirm the diagnosis, assess the size and type of hernia, and evaluate esophageal motility
Esophageal manometry to assess lower esophageal sphincter (LES) pressure and esophageal peristalsis, particularly important if dysphagia is a prominent symptom or if a full fundoplication is planned
24-hour pH monitoring or impedance testing to objectively document reflux, especially in cases of atypical symptoms or failure of medical therapy.
Medical Optimization:
Optimization of nutritional status
Cessation of smoking and alcohol consumption
Review and adjustment of medications, particularly those affecting LES pressure or gastric motility
Patients on anticoagulants will require careful perioperative management and potential temporary discontinuation
Proton pump inhibitor (PPI) therapy may be continued perioperatively to manage residual acid exposure.
Surgical Procedure
Approach Options:
Laparoscopic approach is the preferred method due to its advantages of smaller incisions, reduced postoperative pain, shorter hospital stay, and faster recovery
Open laparotomy may be considered in cases of emergency, previous extensive abdominal surgery with adhesions, or if laparoscopic expertise is unavailable
Robotic-assisted surgery offers enhanced visualization and dexterity.
Steps Of Repair:
Creation of a pneumoperitoneum (laparoscopic) or abdominal incision
Mobilization of the gastroesophageal junction and identification of the hiatal defect
Division of short gastric vessels to fully mobilize the stomach fundus
Reduction of the herniated stomach back into the abdominal cavity
Dissection and mobilization of the diaphragmatic crura
Crural repair: The crura are approximated and sutured together using non-absorbable sutures to narrow the hiatus to approximately 1-2 cm around the esophagus
This is a key step in preventing recurrence
Sleeve fundoplication: A partial fundoplication (e.g., Dor fundoplication, anterior 180-degree wrap) is performed, wrapping the gastric fundus around the anterior aspect of the distal esophagus
The wrap is then secured to the esophagus
A gastropexy may also be performed
Transabdominal or transthoracic repair are open alternatives with similar principles
Placement of a nasogastric tube and potentially a chest tube if a transthoracic approach is used
Closure of the abdominal incision.
Anesthesia Considerations:
General anesthesia with endotracheal intubation is typically used
Careful anesthetic management is required to maintain adequate ventilation, especially with pneumoperitoneum, and to manage intraoperative fluid shifts
Postoperative pain control is essential, often involving multimodal analgesia including intravenous opioids, NSAIDs, and regional blocks.
Postoperative Care
Immediate Postoperative:
Monitoring of vital signs, fluid balance, and pain levels
Nasogastric tube decompression if present
Early ambulation to prevent deep vein thrombosis and pulmonary complications
Clear liquids initiated as tolerated, gradually advancing to a soft diet over 1-2 weeks
Pain management with analgesics
Antiemetics to prevent nausea and vomiting.
Dietary Advancement:
Initial diet is clear liquids, progressing to full liquids, then to pureed and soft foods over several days to weeks
Avoidance of carbonated beverages, chewing gum, and foods known to cause gas or bloating
Patients are advised to eat small, frequent meals and to chew food thoroughly
Gradual reintroduction of a normal diet as tolerated over 4-6 weeks
Long-term dietary modifications may be necessary for some patients.
Follow Up And Monitoring:
Routine follow-up appointments at 2 weeks, 1 month, and 3-6 months postoperatively
Assessment of symptom resolution, dietary tolerance, and any signs of complications
Endoscopy may be considered at 3-6 months to assess the repair and rule out complications like wrap slippage or stenosis
Patients are advised to report any new or worsening symptoms, such as severe dysphagia, persistent vomiting, or severe abdominal pain, immediately.
Complications
Early Complications:
Bleeding from the operative site or within the abdomen
Injury to adjacent organs such as the spleen, liver, or esophagus
Gastric perforation
Pneumothorax or hemothorax (especially with transthoracic approach)
Wound infection
Deep vein thrombosis (DVT) and pulmonary embolism (PE)
Anesthesia-related complications
Gastric outlet obstruction due to edema or malpositioning of the wrap.
Late Complications:
Recurrence of hiatal hernia, particularly if crural repair was inadequate
Dysphagia or odynophagia due to esophageal stenosis or tight wrap
Gas-bloat syndrome, characterized by abdominal distension and inability to belch
Marginal ulcers at the gastrojejunal anastomosis if a gastric bypass is combined or if the wrap is too tight
Esophagitis or peptic ulceration within the wrap
Nutritional deficiencies (rare)
Diaphragmatic dysfunction
Migration or slippage of the fundoplicated wrap.
Prevention Strategies:
Meticulous surgical technique, including adequate mobilization of the esophagus and stomach, precise crural plication to narrow the hiatus appropriately, and secure fixation of the fundoplication
Careful selection of patients and appropriate preoperative assessment
Vigorous DVT prophylaxis and early ambulation postoperatively
Judicious use of nasogastric tube decompression
Careful dietary advancement and patient education regarding eating habits
Use of absorbable sutures for crural repair may be considered by some surgeons to minimize the risk of late dehiscence, though non-absorbable are more common for durable reinforcement.
Key Points
Exam Focus:
Understand the types of hiatal hernias and indications for surgical repair
Differentiate between primary GERD management and surgical indications
Recall the steps of laparoscopic repair with crural reinforcement and sleeve fundoplication (Dor/Toupet)
Identify potential early and late complications and their management
Emphasize the role of crural plication in preventing recurrence.
Clinical Pearls:
For paraesophageal hernias, prioritize repair even with mild symptoms due to the high risk of acute complications like gastric volvulus
During crural repair, ensure the hiatus is snug but not so tight as to cause dysphagia
Consider a partial fundoplication (Dor or Toupet) over a full Nissen fundoplication in patients with pre-existing esophageal dysmotility to reduce the risk of dysphagia and gas-bloat syndrome
Intraoperative assessment with laparoscopic ultrasound or intraoperative endoscopy can confirm hiatus closure and wrap integrity.
Common Mistakes:
Inadequate crural repair leading to early recurrence
Overtightening of the hiatus or fundoplication, causing dysphagia or gas-bloat syndrome
Failure to fully mobilize the stomach, leading to tension on the repair
Inadequate division of short gastric vessels
Ignoring signs of gastric outlet obstruction preoperatively or postoperatively
Insufficient crural dissection, preventing effective plication.