Paraesophageal hiatal hernia. Operations for paraesophageal hernias

Paraesophageal hiatal hernias are less common. They differ from sliding hernias in that the esophageal-biliary junction remains fixed to the preaortic fascia and the medial arcuate ligament below the diaphragm. With these hernias, there is no cardia insufficiency. Paraesophageal hernias have a peritoneal sac surrounding the stomach that has migrated into the chest wall. Complications of paraesophageal hernias are exclusively mechanical, sometimes very serious. The stomach gradually rises into the chest, first by the fundus, and then by the greater curvature, which, as it rises, turns upward, while the lesser curvature remains in the lower position. Over time, the entire stomach, enveloped by the parietal pleura, can migrate into the chest cavity. Despite the migration of the entire stomach into the thorax along with the migration of other abdominal organs, the esophageal-bile junction remains fixed in the normal subphrenic position. In some cases, the esophageal-biliary junction can also migrate into the chest, then there is a mixed hernia, in which cardia insufficiency is often found. 

The mortality rate in complications of paraesophageal hernias is high, therefore, although these hernias are asymptomatic, it is advisable to operate on such patients before complications arise, while in their general condition they can undergo the operation. It has been shown that patients should be operated on when 60-70% of the stomach migrates into the chest. Surgery for paraesophageal hiatal hernias is easier than for a sliding hernia, since in most cases there is no need to perform angareflux surgery. The stomach and other organs that have migrated into the chest cavity are removed, the hernial sac is resected and the hole in the diaphragm is sutured. If the esophageal-gallbladder junction is fixed below the diaphragm, precautions must be taken not to disturb this fixation. Antireflux surgery should be performed only for mixed hernias. Some authors, however, recommend antireflux surgery in all cases of paraesophageal hernias. A complete preoperative examination of patients helps to resolve the issue of the presence of a concomitant sliding hernia with reflux. Surgical access for paraesophageal hernias is not difficult, usually the operation is performed through the abdominal cavity. In patients with symptoms suggesting a complication of hernia by volvulus, entrapment, ischemia, gangrene, or perforation, a thoracic or thoracoabdominal approach should be used. The author uses abdominal access in uncomplicated cases. If necessary, it can be supplemented with thoracotomy in patients in whom the hernial sac is fused with the mediastinum or the stomach is fused with the hernial sac. The described method was proposed by Ellis et al. 

An upper midline laparotomy was performed . If a wider operating field is required, the xiphoid process is resected and the incision is extended 5 or 6 cm below the navel. Open the peritoneum and insert a large self-retaining Balfour retractor. It is useful to have a hand retractor available to raise the lower sternum and costal margin and facilitate inspection of the hiatal opening. The figure shows that in a patient with an asymptomatic course of the disease, more than half of the stomach has migrated to the chest. The Harrington retractor raises the left lobe of the liver. As noted earlier, it is not always necessary to transect the left triangular ligament of the liver for good visualization of the esophageal opening. In some patients, the stomach completely rotates and rises into the chest. Rotation of the stomach can entrain the greater omentum and the transverse colon. In some cases, the loops of the small intestine also migrate to the chest wall.

Using gentle traction with the right hand, the stomach is lowered into the abdominal cavity. The same is done if another organ has migrated into the chest. Some patients have adhesions of the stomach with a hernial sac. The same may be the case with other migrated organs. In such situations, it is sometimes very difficult to lower the organ using only the abdominal approach. Then the incision can be extended to the chest, but it is better to suture the abdominal incision, change the position of the patient and then operate on the paraesophageal hernia with thoracic access.  

After lowering the stomach, the hernial sac is resected by traction down into the abdominal cavity with an Allis or Babcock forceps and using blunt tissue separation. The hernial sac must be resected to prevent possible recurrence of the hernia. 

The stomach is brought down into the abdominal cavity , and the hernial sac is resected. The rest of the operation consists of suturing the esophageal opening of the diaphragm with separate silk and cotton sutures, as can be seen in the figure. Suturing is performed in front of the stomach, and not behind, as in sliding hiatal hernias with reflux, so as not to disrupt the normal fixation of the esophageal-gastric junction to the preaortic fascia and the medial arcuate ligament.

Suturing of the esophageal opening of the diaphragm in front of the stomach is complete; check the correct suture. If the tip of the right index finger can be advanced between the wall of the esophagus with a nasogastric tube (18 F) inside and the edge of the esophageal opening, suturing can be considered correct. In patients in whom most or all of the stomach, as well as other abdominal organs, have migrated into the chest, it is advisable to complete the gastrostomy surgery, as shown in the inset. A gastrostomy tube fixes the stomach to the abdominal wall, reducing the likelihood of recurrence by migrating the stomach into the chest wall. 

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