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Paraesophageal Hernia Repair

Paraesophageal Hernia Repair. Morgan Randall. Paraesophageal Hernia. Indications. Patients with a PEH will present with : Gastroesophageal Reflux Disease (GERD ) Dysphagia Epigastric Pain Vomiting Barrett’s Epithelium Postprandial Fullness or Pain Pulmonary Dysfunction.

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Paraesophageal Hernia Repair

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  1. Paraesophageal Hernia Repair Morgan Randall

  2. Paraesophageal Hernia

  3. Indications • Patients with a PEH will present with: • Gastroesophageal Reflux Disease (GERD) • Dysphagia • Epigastric Pain • Vomiting • Barrett’s Epithelium • Postprandial Fullness or Pain • Pulmonary Dysfunction

  4. Preoperative Tests • Chest X-Ray • Barium Esophagram • Esophagogastroduodenoscopy • Esophageal pH Study • CT Scan (rare) • MRI (rare) • Pulmonary Function Test (rare)

  5. Classification • Type I • not considered a true PEH • Upward migration of the GE junction into the mediastinum • Hernia sac consists of visceral peritoneum, paraesophageal membrane, anterior wall of gastric cardia • Type II • Upward dislocation of fundus of stomach alongside a normally positioned intraabdominal GE junction

  6. Classification cont. • Type III • Upward displacement of both GE junction and gastric fundus • More common than Type II • Type IV – aka Giant • Contains viscera other than stomach

  7. Laproscopicvs Open • Advantages of Laproscopic Procedure • Quicker Recovery • Decreased Length of Hospital Stay • Quicker Return to Normal Activities • Reduced Recurrence Rate • Fewer Infections • Smaller Incisions • Advantages of Open • Increased Abdominal Access

  8. Contraindications • Contraindications for the laparoscopic approachAbsolute contraindications: • abdominal or mediastinal perforation. • Relative contraindications • single or multiple recurrences in patients with multiple abdominal scars (the thoracic route may be indicated in these patients),

  9. Instruments Used • Scalpel • Syringe • 5mm, 10mm, 12mm Trocars • 30° Laproscope • Liver Retractor • Harmonic Scalpel • Atraumatic Graspers • Articulating Grasper • Penrose Drain • 56 French Bougie • Suction/Irrigation System • Endo Universal 65 Stapler • Bioilogic Implant Mesh • Suture • 0 Braided Silk • 2-0Braided Silk

  10. Room Setup

  11. Port Placement

  12. Port Placement 10mm Port 15 cm 5mm Port 5mm Port 12mm Port

  13. Room Setup

  14. Place Liver Retractor

  15. Important Structures http://upload.wikimedia.org/wikipedia/commons/4/4b/Gray793.png http://www.biology-online.org/articles/computer_simulation_analysis_normal/figures.html http://www.med.umich.edu/anatomy/plastinate/galleries/Green_Lab/Abdominal_Cross_Section.html

  16. Hernia Dissection

  17. Mobilize Fundus of Stomach

  18. Place Penrose Drain

  19. Hernia

  20. Stitch Hernia Closed

  21. Stitch Hernia Closed

  22. Add Mesh and Staple in Place

  23. Nissen Fundoplication

  24. Endoscopy to Check Alignment

  25. Questions?

  26. Thank You

  27. Refrences • Special Thanks to Dr. John Roth • Benign Esophageal Disease. Thoracic Surgery. Stanford School of Medicine. http://thoracicsurgery.stanford.edu/patient_care/benign_esophageal.html • Pierre, Andrew F. and Luketich, James D. Laproscopic Repair of Giant Paraesophageal Hernias. Cardiothoracic Surgery Network. http://www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-9.html • Paraesophagel Hernia. Mount Sinai School of Medicine. http://www.mssurg.net/Team5Conferences/Paraesophageal%20Hernia%20-2.pdf • Laparoscopic Paraesophageal Hernia. Ohio State University Center for Minimally Invasive Surgery. The Ohio State University. Department of Surgery. http://cmis.osu.edu/8818.cfm • www.websurg.com • UK HealthCare. Hernia Facts Sheet. http://www.ukhealthcare.uky.edu/publications/healthfocus/fact_sheets/hernias.asp

  28. Endo Universal 65 http://www.covidien.com/hernia/us/fixation/endouniversal RETURN

  29. 30° Endoscope http://www.stryker.com/en-us/products/Endoscopy/Laparoscopy/Laparoscopes/StandardLengthLaparoscopes/index.htm RETURN

  30. Trocar • Available in 5mm, 8mm, 10mm, 12mm RETURN http://www.ethiconendosurgery.com/Clinician/Product/access/trocars/xcelbladeless#About

  31. Biologic Implant Mesh http://www.covidien.com/hernia/us/biologics/permacol RETURN

  32. Maryland Dissector http://www.ethiconendosurgery.com/Clinician/Product/endodevices/endohandinstruments#description-specs RETURN

  33. Penrose Drain http://www.covidien.com/criticalcare/pageBuilder.aspx?webPageID=0&topicID=67861&xsl=xsl/productPagePrint.xsl RETURN

  34. 56 French Bougie http://www.stryker.com/en-us/products/Endoscopy/Laparoscopy/AccessoriesandDisposables/InfraVisionEsophagealKit/index.htm RETURN

  35. Articulating Grasper http://www.covidien.com/autosuture/pagebuilder.aspx?topicID=195028&breadcrumbs=0:63659,172308:0,195057:0 RETURN

  36. Suction/Irrigation System http://www.endotek.com.tr/default.asp?L=EN&mid=173&cat_id=216 RETURN

  37. Scalpel http://www.google.com/search?hl=en&sugexp=ldymls&xhr=t&q=scalpel&cp=6&bav=on.2,or.r_gc.r_pw.&wrapid=tljp1303234486536010&um=1&ie=UTF-8&tbm=isch&source=og&sa=N&tab=wi&biw=1259&bih=617 RETURN

  38. Harmonic Scalpel http://www.ethiconendosurgery.com/Clinician/Product/energy http://www.hhsurgical.com/Products/Product/Electrosurgical-Units/NoSub/1445-Ethicon-G110-Harmonic-Scalpel-.chtml RETURN

  39. Syringe http://www.mediray.com/Pages/Products/SyringeShields.html RETURN

  40. Liver Retractor http://www.bristolsurgery.com/article.aspx?articleid=100749 RETURN

  41. Suture http://www.syneture.com/syneture/pageBuilder.aspx?topicID=315 http://www.sosmedicalsuperstore.com/PhotoGallery.asp?ProductCode=A306H RETURN

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