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Hand Assited Minimally Invasive Repair of Recurrent Hiatal Hernia
Trevor C. Upham, MD, Nadim G. Haddad, MD, M. Blair Marshall, MD.
Georgetown University Medical Center, Washington, DC, USA.
OBJECTIVE: Re-operative repair of recurrent hiatal hernia is often performed through open technique, in particular when the previous repair has been performed with open techniques. However, the view of the hiatus with an open approach can be difficult when performed via thoracotomy of laparotomy. Minimally invasive techniques using angled cameras that magnify the view often provide better visualization but the lack of tactile feedback is of concern in re-operative surgery. We present a combined technique with the use of the hand-port to demonstrate the optimal visualization in concert with the ability to use tactile feedback in re-operative hiatal surgery.
METHODS: We present a 62 year old male who underwent previous hiatal hernia repair through open abdominal approach over 20 years prior, recurred and underwent a left thoracotomy with Belsey repair in 1996. He recurred and underwent an endoscopic repair by his gastroenterologist in 2004. He presented in 2011 symptomatic from another recurrence. He was counseled on the need for a larger procedure given his frequent recurrences but he requested attempt at a repeat repair.
RESULTS: The repair was performed with an upper midline hand-port, 3 additional 5 mm ports and one 10mm port. A 5mm 30o camera was used. The adhesions were lysed, the previous repair taken down. The esophagus was not shortened, so a porcine based mesh was used to reconstruct the hiatus and a modified fundoplication was performed with a temporary gastrostomy tube. He was discharged home on post-operative day 2 and is well without recurrence 18 months following the procedure.
CONCLUSIONS: Re-operative hiatal surgery, in particular after open procedures can be performed with minimally invasive techniques. The use of an angled camera affords excellent visualization of the hiatus and lower mediastinum. The hand-port allows for tactile feedback, critical for the proper identification of structures during re-operative surgery. This combined approach is ideal for re-operative hiatal surgery.
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