Indications Patients with a PEH will present with:
Gastroesophageal Reflux Disease (GERD) Dysphagia Epigastric Pain
Vomiting Barretts Epithelium Postprandial Fullness or Pain
Pulmonary Dysfunction
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Preoperative Tests Chest X-Ray Barium Esophagram
Esophagogastroduodenoscopy Esophageal pH Study CT Scan (rare) MRI
(rare) Pulmonary Function Test (rare)
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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
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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
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Laproscopic vs 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
Slide 9
Contraindications Contraindications for the laparoscopic
approach Absolute 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),
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
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Hernia Dissection
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Mobilize Fundus of Stomach
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Place Penrose Drain
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Hernia
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Stitch Hernia Closed
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Add Mesh and Staple in Place
Slide 24
Nissen Fundoplication
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Endoscopy to Check Alignment
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Questions?
Slide 27
Thank You
Slide 28
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/herni
as.asp