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Laparoscopic Hiatal Hernia Repair mayo stand and back table surgery setup

Diana Lei-aloha Avatar

setup author

Laparoscopic Hiatal Hernia Repair surgery instruments

Clamping & Occluding instruments

Endo clip applier
Endo clip applier
Kelly Forceps
Kelly Forceps

Cutting & Dissecting instruments

Laparoscopic Metz Scissor
Laparoscopic Metz Scissor
Metzenbaum Scissor
Metzenbaum Scissor
Straight Mayo Scissor
Straight Mayo Scissor

Grasping & Holding instruments

Fundus Laparoscopic Grasping Forceps
Fundus Laparoscopic Grasping Forceps
Dissecting Laparoscopic Grasper Forceps
Dissecting Laparoscopic Grasper Forceps
Cobra Laparoscopic Grasper
Cobra Laparoscopic Grasper
Laparoscopic Bowel Grasper
Laparoscopic Bowel Grasper
Laparoscopic Maryland Dissector Grasper
Laparoscopic Maryland Dissector Grasper

Retracting & Exposing instruments

Army-Navy Retractor
Army-Navy Retractor
Senn Retractor
Senn Retractor
Hasson S Retractor
Hasson S Retractor
Nathanson Hook Liver Retractors
Nathanson Hook Liver Retractors

Suctioning instruments

Suction Irrigator
Suction Irrigator
Yankauer Suction
Yankauer Suction

Suturing & Stapling instruments

Laparoscopic Clip Appliers
Laparoscopic Clip Appliers
Mayo-Hegar Needle Holder
Mayo-Hegar Needle Holder
Laparoscopic Needle Holder
Laparoscopic 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.

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4 responses to “Laparoscopic Hiatal Hernia Repair”

  1. Kim Witten Avatar
    Kim Witten

    Do you have any tips on loading the Endostitch? My needle never wants to stay loaded

    1. Diana Lei-aloha Avatar
      Diana Lei-aloha

      Loading the Endostitch took a lot of practice for me! My biggest tip is to make sure the Endo stitch tip is lined up properly in the cartridge. It can’t be too low, too high, or slightly off to the side. Once it’s lined up, close the tips and pull down on the blue/green levers to capture the needle. Your needle shouldn’t fall off now!

  2. mountaincat_1 Avatar
    mountaincat_1

    In step 5, the gastroplasty is performed using a stapler, use the endo stitch to partially close the window that was formed. Is the window referring to the hiatus in the diagram? I’m fairly new and haven’t seen or done one of these yet.

    1. Diana Lei-aloha Avatar
      Diana Lei-aloha

      Yes, exactly! I will specify that in the post. Thank you for asking me to clarify!

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