Hiatal & Paraesophageal Hernia Repair (Open, Laparoscopic, Robotic)

Procedure Snapshot

• Indication: Symptomatic large sliding or paraesophageal hernia (reflux, obstruction, bleeding).
• Expected duration: ___
• Special instruments: Bougie, laparoscope, tacker, mesh (optional).

Step Workflow

1. Establish laparoscopy; reduce stomach into abdomen.
2. Excise hernia sac; mobilize esophagus ≥ 3 cm below diaphragm.
3. Approximate crura posteriorly with nonabsorbable sutures.
4. Perform fundoplication (360° Nissen or 270° Toupet).
5. Consider mesh reinforcement if large defect.
6. Confirm no wrap obstruction.

Key Pimp Questions

• Q: Why posterior crural closure?
  A: Restores anatomy and prevents recurrence.
• Q: How to avoid gas bloat syndrome?
  A: Short, loose wrap over calibrated bougie (PMID 31852916).

Critical Anatomy

• Landmarks: Esophageal hiatus, vagus nerves, phrenoesophageal ligament.
• Danger zones: Pleura, pericardium, vagus trunks.

Informed Consent Highlights

• Risks: Dysphagia __, gas bloat __, recurrence ___.

Post-op Considerations

• Clear liquids POD 1; soft diet × 2 wks.
• Avoid heavy lifting × 6 wks.

References

• Chassin’s, Foregut section.
• Clinical Scenarios, Esophagus/Stomach.
• Furnée 2020 (PMID 31852916).