1. Dr. Karem Batniji Department of Surgery , SMC
Giant Hiatal Hernia Repair Left Triangular Ligament Anterior Hiatoplasty
Dr. Karem Batniji
Department of Surgery , SMC
Dr Karem Batniji Department Of Surgery, SMC
6/30/2018

2. INTRODUCTION
A giant hiatal hernia (HH) is a hernia that includes at least 30% of the stomach in the chest, most commonly, a giant HH is a type III - IV hernia.
However; Abbreviated descriptions of hiatal hernia such as HH I-IV do not influence the choice of operative technique to be used.
Perfected classification: (O Ospanov et al )
Width (W): most important; W1 < 3 cm; W2, 3-5 cm; W3, 5-8 cm; and W4 > 8 cm.
Length (L): L1 < 5 cm; L2, 5-8 cm; and L3 ≥ 8 cm.
Grade of short esophagus (SE): with SE0, no shortening; SE1, shortening by ≤ 4 cm; and SE2, shortening by > 4 cm.
Hiatal hernia recurrence (R): R0, no recurrence and R (n), the number of previous hernia repairs.
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

3. BACKGROUND
Tension-free closure of the esophageal hiatus is a key step to laparoscopic hiatal hernia repair.
Usually, this is achieved with simple interrupted sutures (i.e., posterior hiatoplasty).
However, non-compliant crura / elevated radial tension at the hiatus  primary closure may be impossible or ONLY achievable under significant tension.
Closure under tension significantly contributes to recurrence, (>50 %).
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

4. BACKGROUND
When faced with a difficult diaphragmatic closure, surgeons have several options:
Use mesh or an autologous tissue flap (e.g., falciform ligament, teres ligament).
Pleurotomy (intentional pneumothorax) or diaphragmatic (crural) relaxing incisions.
Perform a gastropexy without closure of the hiatus.
These techniques appear to be safe.
However, long-term ability to prevent recurrent hiatal hernia has not been fully assessed yet.
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

5. PATIENT DESCRIPTION A 60 y/o lady
Long standing dyspnea on effort, chest pain, GERD and upper abdominal fullness.
Hx hypothyroidism and hypertension (controlled).
Hx abdominal hysterectomy 1 year earlier.
PE unremarkable.
Lab. Tests: within normal.
EGD (report) : big hiatal hernia.
Swallow study (report) : huge HH.
CT scan:
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

6. PATIENT DESCRIPTION Dr Karem Batniji 6/30/2018
Department Of Surgery, SMC
6/30/2018

7. PATIENT DESCRIPTION Dr Karem Batniji 6/30/2018
Department Of Surgery, SMC
6/30/2018

8. INTERVENTION
Preoperative: optimization, Anesthesia, patient counselling.
GA, modified lithotomy, laparoscopic approach.
Gigantic hiatus, GE junction, stomach/colon and omentum in the chest.
Sac dissected (ant./post.) then excised.
Crural dissection, non-compliant and widely separated.
Esophagus mobilized to adequate intra abd. portion.
Posterior cruroplasty performed to the extent possible
360⁰ wrap performed.
Anterior hiatal defect closed by tension free suture darning.
Lt ∆ lig. Mobilized over the ant hiatus, fixed to the crura.
Gastropexy done.
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

9. INTERVENTION
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

10. RESPONSE TO TREATMENT Smooth postoperative course.
NG tube removed on day 2 , sips of water allowed.
Day 3: Tube drain removed , patient discharged.
OPD (1wk, 4 wk, 14 m) : No clinical evidence of recurrence.
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

11. LITERATURE
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

12. DISCUSSION A successful repair of giant HH requires:
Adherence to basic hernia repair principles (ie, hernia sac excision, tension-free repair),
Recognition and correction of a short esophagus,
Well-performed anti-reflux procedure.
Lt ∆ ligament repair is possible and probably safe.
Further studies to validate the long term results are needed.
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

13. REFERENCES
Aye, R. W., & Hunter, J. G. (2016). Fundoplication Surgery. Springer International Publishing:.‏
Ghanem, O., Doyle, C., Sebastian, R., & Park, A. (2015). New surgical approach for giant paraesophageal hernia repair: closure of the esophageal hiatus anteriorly using the left triangular ligament. Digestive surgery, 32(2), ‏
Scott-Conner, C. E. (2013). Scott-Conner & Dawson: Essential Operative Techniques and Anatomy. Lippincott Williams & Wilkins.‏
Louie, B. E., Blitz, M., Farivar, A. S., Orlina, J., & Aye, R. W. (2011). Repair of symptomatic giant paraesophageal hernias in elderly (> 70 years) patients results in improved quality of life. Journal of Gastrointestinal Surgery, 15(3), ‏
Aly, A., Munt, J., Jamieson, G. G., Ludemann, R., Devitt, P. G., & Watson, D. I. (2005). Laparoscopic repair of large hiatal hernias. British journal of surgery, 92(5), ‏
O Ospanov, R Khasenov, I Volchkova. Intraoperative Measurement, Classification, And Abbreviated Description Of Hiatal Hernias. The Internet Journal of Surgery Volume 27 Number 1
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018

14. THANK YOU
Dr Karem Batniji
Department Of Surgery, SMC
6/30/2018