Upload
jayaraj-karunanidhi
View
1.014
Download
0
Tags:
Embed Size (px)
Citation preview
1
Paraesophageal Hiatal Hernia
2
• The esophageal hiatus is formed by the right crus and little or no left crus.
• The phrenoesophageal ligament, which holds the distal esophagus in place is formed by fusion by endothoracic and endoabdominal fascia at the esophageal hiatus.
3
CLASSIFICATION
• There are 4 types of hiatal hernias.
• The sliding hernia or type I is the most common.
4
Type I Hiatal Hernia
• The E-C junction moves through the hiatus to the visceral mediastinum.
• Increased abdominal pressure( pregnancy, obesity, or vomiting ) and vigorous esophageal contraction may contribute the development of the hernia.
• G-E reflux and esophagitis may occur due to loss of tone of the LES.
5
Type II Hiatal Hernia
• It is uncommon.
• The phrenoesophageal membrane is not weakened diffusely but focally.
• The gastric fundus protrudes through the hiatus.
6
52-1
7
Type III Hiatal Hernia
• It is combined with type I and type II.
• It is frequently present when a type II hiatal hernia have been present for many years.
8
Type IV Hiatal Hernia
• It refers hernia of organs other than the stomach.
• The T-colon and the omentum are the most common involved.
• The spleen and the small intestine may be involved.
9
ANATOMY AND PHYSIOLOGY
• In a true paraesophageal hiatal hernia, the lower esophagus and the cardia remain fixed below the diaphragm in the posterior aspect of the diaphragmatic hiatus.
• The herniated organs are covered with a layer of the peritoneum that forms a true hernia sac, unlike the type I hiatal hernia, in which the stomach forms the posterior wall of hernia sac.
10
ANATOMY AND PHYSIOLOGY
• Complications are bleeding, incarceration, volvulus, obstruction, strangulation and perforation.
• Gastritis and ulceration have been seen. The ulcer are the result of poor gastric emptying and torsion of the gastric wall.
11
SYMPTOMS
• Many type I and type II hernia have few or no symptoms.
• Bleeding results from gastritis and ulcer can induce IDA, resulting in fatigue and exertional dyspnea.
• Postprandial discomfort may occur. The substernal fullness is often mistaken MI.
12
SYMPTOMS
• In type II hernia, G-E reflux and true dysphagia is uncommon.
• If vovulus occurs, severe pain and pressure in the chest or epigastic region.
• Fever, hypovolemic shock will be present if volvulus progresses and strangulation occurs. In this situation, mortality rate is 50%.
13
DIAGNOSIS
• The diagnosis is suspected first on the CXR.• The most common finding is retrocardiac b
ubble with or without air-fluid level.• In a giant hiatal hernia, the herniated organ
may be found in the right thoracic cavity.• D.D: mediastinal cyst or abscess, dilated ob
structed esophagus, as end stage of achalasia.
14
DIAGNOSIS
• The barium study of the UGI confirms the diagnosis.
• Endoscopy and esophageal function test can detect the function of LES.
15
THERAPY
• There is no accepted medical treatment for hiatal hernia.
• Surgery is indicated to prevent complications.
• In type II hernia, if gastric volvulus or obstruction is present without toxic signs, NG decompression must be performed. The surgery is scheduled.
16
Operative Approaches
• The operation or operative approach is controversial.
• The principles of operation is reduction of the hernia, resection of the hernia sac and closure of the defect.
• It is easy to do intrathoracic dissection via thoracotomy.
• However, transthoracic reduction may lead to volvulus of the gastric body.
17
Operative Approaches
• Abdominal approach is also suggested.• Additional procedures can be done, such as
gastrotomy, which obviates the NG tube and decreases the risk of recurrent volvulus.
• Abdomional approach is difficult to do in type III hiatal hernia with G-E reflux and a foreshortened esophagus.
• Laparoscopic repair is also advocated.
18
Should a Antireflux Procedure Be Induced?
• It is controversial.
• It is indicated in patients with esophagitis by symptoms and endoscopy, with a hypotensive LES( < 10 mmHg ) or positive 24-hour pH monitoring.
19
Operative Technique: Conventional Abdominal Approach
• The author prefers abdominal approach via upper midline incision.
• In type II hernia, the E-C junction is still in the abdomen, bounded posteriorly with a fibrous band. It is careful not to take down the attachment.
• Dissection is done on the lower 4 to 8 cm of the esophagus.
• The repair is done with nonabsorbable O sutures.
20
Operative Technique: Conventional Abdominal Approach
• Antireflux procedure is done when significant reflux esophagitis is present.
• A loose Nissen fundoplication is suggested by authors.
• If no fundoplication is performed then the stomach can be fixed by two methods: Hill suture plication and Stamm gastrostomy.
21
Operative Technique: Conventional Abdominal Approach
• Hill suture plication: 3 interrupted nonabsorbable sutures between lesser curve of the stomach and preaortic fascia
• Stamm gastrostomy: 2 functions
1. It eliminates the need of NG tube.
2. It fixes the stomach to the abdominal wall
and to prevent volvulus.
22
• 52-5
23
Operative Technique: Laparoscopic Approach
24
52-6
25
Operative Morbidity and Mortality
• The operative mortality is less than 0.5%.• If gasric volvulus occurs, the operative mort
ality is up to 14%.• Pulmonary complication may be seen in pat
ients with aspiration resulting from volvulus or obstruction.
• Complication of gastric stasis may result from edema of the released gastric segment.
26
Operative Morbidity and Mortality
• Other complications include gastric perforation, gastric bleeding, slipped Nissen fundoplication, small bowel obstruction and atelectasis.
27
RESULTS
• Long-term results are excellent.
• Simultaneous antireflux procedure is ineffective prophylaxis against recurrent herniation resultant G-E reflux.
• The long-term result after laparoscopic repair is unknown.
28
Thank You!