Mayo stand and back table instruments for Laparoscopic Hiatal Hernia Repair surgery setup

Clamping & Occluding

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  Endo clip applier

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  Kelly Forceps

Cutting & Dissecting

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  Laparoscopic Metz Scissor

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  Metzenbaum Scissor

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  Straight Mayo Scissor

Grasping & Holding

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  Cobra Laparoscopic Grasper

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  Dissecting Laparoscopic Grasper Forceps

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  Fundus Laparoscopic Grasping Forceps

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  Laparoscopic Bowel Grasper

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  Laparoscopic Maryland Dissector Grasper

Retracting & Exposing

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  Army-Navy Retractor

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  Hasson S Retractor

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  Nathanson Hook Liver Retractors

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  Senn Retractor

Suctioning

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  Suction Irrigator

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  Yankauer Suction

Suturing & Stapling

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  Laparoscopic Clip Appliers

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  Laparoscopic Needle Holder

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  Mayo-Hegar Needle Holder

What to expect during Laparoscopic Hiatal Hernia Repair

Laparoscopic hiatal hernia repair is a surgical procedure used to fix a type of hernia that occurs when a portion of the stomach protrudes through the diaphragm into the chest cavity. The procedure involves using specialized instruments and a laparoscope to repair the hernia, reduce the protrusion of the stomach, and prevent acid reflux. It is a minimally invasive surgery that is usually performed under general anesthesia.

Positioning
Supine with foot board

Drapes
Folded towels or utility drapes and laparoscopy drape

Anesthesia
General

Step 1: Preparing for Surgery
After the patient has been put under general anesthesia, a Foley catheter will be inserted, and they will be prepped and draped for the procedure. The patient’s bed should be placed in reverse Trendelenburg, and the footboard should be attached to the bed.

Step 2: Creating Ports and Insufflation
An 11 or 15 blade (surgeon’s preference) is loaded onto a #3 knife handle and used to make the first incision for a 10mm port. Insufflation tubing will be connected to the port, and the CO2 will be turned on by the circulator. A laparoscope will be connected to the camera and light cord and inserted through the port to look around. A couple of 5mm ports will be placed for the instruments to be placed through.

Step 3: Finding the Hiatal Hernia
The hiatal hernia will be located after placing the bed in reverse Trendelenburg. A liver retractor will be inserted through one of the ports to hold it out of the way for the entire case.

Step 4: Dissecting Adhesions and Mobilizing the Esophagus
A variety of laparoscopic instruments such as wave graspers, Debakey graspers, Maryland dissectors, and a Harmonic scalpel will be used to take down adhesions and get to the hernia. The surgeon will dissect until the hernia sac is reduced into the abdomen. Once that is done, the esophagus will be mobilized to get the length that is needed. The surgeon will divide the short gastric vessels and move the fat pad off of the stomach to see the gastroesophageal junction (GEJ).

Step 5: Gastroplasty and Mesh Insertion
A bougie will be placed to prevent GEJ constriction. An endo stapler (commonly several 16mm loads) will be used to perform a gastroplasty to lengthen the esophagus even more. Once the stapler has been fired, a wedge will be made. An EndoStitch will be used to partially close the window that was made. A piece of mesh will then be used to close the rest of the defect. The mesh is cut into a U shape and put around the esophagus. A tacking instrument will be used to attach the mesh to the diaphragm, holding it in place. Excess mesh can be trimmed away with the laparoscopic Metz.

Step 6: Fundoplication and Inspection
Fundoplication will be done using the EndoStitch again. An endoscope will be used to check for any leaks in the staple line. Once there are no leaks found, a suction irrigator can be used to irrigate, and the liver retractor and ports can be removed.

Step 7: Closing Incisions
0 or 2-0 Vicryl is commonly used to close the deep layer of the larger incision, and 3-0 or 4-0 Nylon or Monocryl can be used to close the skin layers.

The Surgery Sparknotes

1. Prep patient, make incision for 10mm port, insert insufflation tubing, insert laparoscope.
2. Place 5mm ports, insert liver retractor.
3. Find hiatal hernia, use laparoscopic instruments to take down adhesions.
4. Mobilize esophagus, divide short gastric vessels, perform gastroplasty.
5. Use EndoStitch to partially close window, use mesh to close defect, trim excess with Metz.
6. Perform fundoplication with EndoStitch.
7. Check for leaks with endoscope, irrigate, remove ports and retractor, close incisions.