DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Type 3 paraesophageal hernia.
POSTOPERATIVE DIAGNOSIS: Type 3 paraesophageal hernia.
OPERATION PERFORMED:
1. Laparoscopic repair of type 3 paraesophageal hernia.
2. Laparoscopic Toupet fundoplication.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: 40 mL.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was transported to the operating room and placed supine on the operating table. Following induction of satisfactory general endotracheal anesthesia, the patient was placed in a dorsal lithotomy position using Allen stirrups and appropriate padding of all pressure points. The abdomen was prepped and draped in the customary fashion using Betadine solution and sterile towels and sheets.
A skin incision was made approximately 8 cm inferior to the xiphoid process, superior to the umbilicus and to the left of the midline. The dissection was carried down to the level of the anterior fascia and the abdominal cavity entered under direct vision using an Optiview trocar. Carbon dioxide gas was instilled, and a satisfactory pneumoperitoneum was achieved without evidence of respiratory compromise. The 30-degree laparoscope with video camera was threaded through this trocar site and the upper abdomen explored. Examination of the right upper quadrant revealed normal-appearing gallbladder and liver. There was no splenomegaly, and the anterior serosal surface of the stomach was not well visualized secondary to the large paraesophageal hernia.
Having completed the exploration, a 10 mm trocar was placed along the left costal margin at the midclavicular line and a 5 mm trocar placed along the left costal margin at the anterior axillary line. Two additional 5 mm trocars were placed in the subxiphoid position as well as in the right upper quadrant lateral to the rectus musculature. The laparoscopic liver retractor was introduced through the right upper quadrant trocar site and used to elevate the left lobe of the liver. This allowed for complete exposure of the esophageal hiatus. A large, type 3 paraesophageal hernia was present, and the stomach and omentum were carefully reduced from the mediastinum. The peritoneal sac was then completely everted, and the peritoneum incised along the border of the left crus using the Harmonic shears.
The gastrohepatic ligament was opened over the caudate lobe of the liver, again with the Harmonic shears, and the peritoneal sac incised along the right crus. The mediastinum was entered and the sac completely mobilized. The anterior and posterior vagal nerve trunks were identified and carefully preserved with the posterior nerve trunk left in place along the posterior wall of the esophagus. The esophagus was circumferentially mobilized, and all vessels encountered controlled with the Harmonic shears. The excess hernia sac was excised and delivered through the 10 mm trocar site. The posterior aspect of the gastroesophageal junction was fully mobilized as well, and a pediatric Penrose drain passed around the esophagus at this level. This was secured in place with a 0 PDS Endoloop. Using the drain for retraction, the esophageal mobilization was completed to allow for approximately 3-4 cm of the esophagus to lie comfortably within the abdominal cavity without tension. The lesser sac was then entered along the greater curvature of the stomach inferior to the inferior pole of the spleen. The short gastric vessels were divided with the Harmonic shears to the level of the left crus and care was taken to ensure that the entire posterior aspect of the upper fundus of the stomach was completely mobilized.
Once this was accomplished, attention was turned to closure of the diaphragmatic defect. This was completed posteriorly using horizontal mattress sutures of 0 Ethibond and felt pledgets. Care was taken to ensure that there was no anterior angulation of the esophagus. An additional suture with pledgets was placed anteriorly to complete closure of the defect, and a tissue patch was placed over the posterior closure for reinforcement. This was secured in place with 3-0 Vicryl suture. At the completion of the repair of the diaphragmatic defect, it appeared to be satisfactory and admitted the #60 Maloney dilator through the esophageal hiatus. The dilator was then withdrawn, and the posterior aspect of the upper fundus of the stomach passed posteriorly to the esophagus. The esophagus appeared to lie comfortably within the bed of the fundus, and there was no evidence of tension. The posterior aspect of the fundus was then secured to the diaphragmatic closure with 2-0 Ethibond sutures.
The Toupet fundoplication was also completed using 2-0 Ethibond sutures. The superior sutures were placed to the 10 o’clock and 2 o’clock positions between the esophagus, diaphragm, and fundus of the stomach. Two additional sutures were placed on either side between the fundus of the stomach and the esophagus. At the completion of the fundoplication, it measured approximately 3 cm in length, and there was no evidence of tension. The entire area of dissection was thoroughly irrigated with Kantrex solution and checked for hemostasis. Any remaining fluid was evacuated, and the suction irrigator used to remove as much carbon dioxide gas as possible. The trocars were removed and the incisions irrigated with Kantrex solution. The fascial opening at the 10 mm trocar sites were closed with 0 Vicryl sutures and 0.5% Marcaine instilled into the incisions. The skin was closed with 4-0 Vicryl subcuticular suture, and Benzoin and Steri-Strips as well as a Tegaderm dressing placed across the incisions. The patient was awakened and transported back to the recovery room in satisfactory condition with sponge and needle counts reported as correct at the end of the procedure.
