Laparoscopic Hiatal / Paraesophageal Hernia Repair

ApproachLaparoscopic

Preoperative Diagnosis:

Symptomatic [type I sliding hiatal hernia / type II paraesophageal hernia / type III mixed hiatal hernia / type IV paraesophageal hernia]

Postoperative Diagnosis:

Same

Procedure Performed:

Laparoscopic [hiatal / paraesophageal] hernia repair with posterior cruroplasty

Attending Surgeon:

[***, MD/DO]

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal

Indications:

The patient is a [age]-year-old [male / female] with a symptomatic [type I sliding hiatal hernia / type II paraesophageal hernia / type III mixed hiatal hernia / type IV paraesophageal hernia] associated with [postprandial pain or fullness / dysphagia / regurgitation / reflux / anemia / dyspnea / obstruction / gastric volvulus]. Preoperative evaluation included [upper endoscopy / esophagram / CT / manometry / reflux testing] and demonstrated [findings]. Operative and nonoperative options were discussed, and informed consent was obtained.

Findings:

A [type I sliding hiatal hernia / type II paraesophageal hernia / type III mixed hiatal hernia / type IV paraesophageal hernia] was identified. The hiatus measured approximately [X × Y] cm. The gastroesophageal junction was [X] cm above the hiatus, and the hernia contained [gastric fundus / gastric body / entire stomach / omentum / colon / other]. The stomach was [viable / ischemic as described] with [no volvulus / organoaxial volvulus / mesenteroaxial volvulus]. The crura were [well developed / attenuated]. Following mediastinal mobilization, the gastroesophageal junction rested approximately [X] cm below the hiatus without caudal traction.

Description of Procedure:

The patient was positioned [supine / split-leg] in reverse Trendelenburg. General anesthesia was induced, and a surgical timeout was completed. Pneumoperitoneum was established using a [Veress / optical / open] technique at [site]. [Four / five] trocars were placed under direct visualization, and the left lobe of the liver was elevated with a retractor.

The herniated [stomach / omentum / colon / other] was reduced using atraumatic traction. [The stomach was decompressed with an orogastric or nasogastric tube.] The gastrohepatic ligament was opened, and the right crus was exposed. The hernia sac was separated from the crural fascia, and the dissection was continued anteriorly and circumferentially to expose the left crus. The sac was [reduced intact / partially excised / excised], and the herniated contents were returned to the abdomen.

A retroesophageal window was developed. The distal esophagus was mobilized within the mediastinum while protecting the esophagus, stomach, pleura, and vagal structures. [The anterior and posterior vagal trunks were identified and preserved / Vagal structures were protected throughout.] [The pleural space was not entered / A pleural opening occurred at *** and was managed with ***.] After mobilization, the gastroesophageal junction rested approximately [X] cm below the hiatus without traction.

The crura were reapproximated posterior to the esophagus with [number] [interrupted / figure-of-eight / mattress] [permanent / slowly absorbable] sutures [with pledgets]. [An anterior crural suture was added.] The closure was inspected and admitted a [bougie / endoscope / instrument] without constricting the esophagus.

[Intraoperative upper endoscopy demonstrated an intact esophagus and stomach, a gastroesophageal junction below the diaphragm, and no evidence of injury or leak.] The stomach and gastroesophageal junction remained below the diaphragm without tension. Hemostasis was confirmed. The liver retractor and trocars were removed under direct visualization, the fascia at sites of [X] mm or greater was closed, and the skin was closed in standard fashion.

Complications:

None

Specimens:

[None / Hernia sac sent to pathology]

Estimated Blood Loss:

Minimal ([X] mL)

Drains:

None

Disposition:

The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Epic SmartPhrase Version

PREOPERATIVE DIAGNOSIS: Symptomatic [type I sliding hiatal hernia / type II paraesophageal hernia / type III mixed hiatal hernia / type IV paraesophageal hernia]
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Laparoscopic [hiatal / paraesophageal] hernia repair with posterior cruroplasty
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with a symptomatic [type I sliding hiatal hernia / type II paraesophageal hernia / type III mixed hiatal hernia / type IV paraesophageal hernia] associated with ***. Preoperative [upper endoscopy / esophagram / CT / manometry / reflux testing] demonstrated ***. Operative and nonoperative options were discussed, and informed consent was obtained.

FINDINGS: [Type I sliding hiatal hernia / type II paraesophageal hernia / type III mixed hiatal hernia / type IV paraesophageal hernia]. Hiatus measured *** cm. GE junction *** cm above the hiatus. Hernia contained [gastric fundus / gastric body / entire stomach / omentum / colon / other]. Stomach [viable / ischemic as described] with [no volvulus / organoaxial volvulus / mesenteroaxial volvulus]. Crura [well developed / attenuated]. After mobilization, the GE junction rested *** cm below the hiatus without traction.

DESCRIPTION OF PROCEDURE:
The patient was positioned [supine / split-leg] in reverse Trendelenburg. General anesthesia was induced, and a surgical timeout was completed. Pneumoperitoneum was established by a [Veress / optical / open] technique. [Four / five] trocars were placed, and the liver was retracted.

Herniated [stomach / omentum / colon / other] was reduced with atraumatic traction. [The stomach was decompressed.] The gastrohepatic ligament was opened. The hernia sac was separated from the crura, dissected circumferentially, and [reduced intact / partially excised / excised]. Both crura were exposed.

A retroesophageal window was developed. The distal esophagus was mobilized in the mediastinum while the esophagus, stomach, pleura, and vagal structures were protected. [Vagal trunks identified and preserved / Vagal structures protected throughout.] [Pleura not entered / Pleural opening at *** managed with ***.] The GE junction rested *** cm below the hiatus without traction.

The crura were closed posteriorly with *** [interrupted / figure-of-eight / mattress] [permanent / slowly absorbable] sutures [with pledgets]. [An anterior crural suture was added.] The closure admitted a [bougie / endoscope / instrument] without constriction. [Upper endoscopy showed intact esophagus and stomach, GE junction below the diaphragm, and no injury or leak.] Final anatomy and hemostasis were satisfactory.

The liver retractor and trocars were removed. Fascia at sites *** mm or greater was closed. Skin was closed in standard fashion.

ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [None / Hernia sac]
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition.

Signed: .ME, .MYDEGREE
.TODAY

Variants

With Nissen Fundoplication

After hiatal closure, the gastric fundus was [mobilized without dividing the short gastric vessels / fully mobilized after division of the short gastric vessels]. The true fundus passed posterior to the esophagus without tension and moved freely during a shoeshine maneuver. A short, loose 360-degree fundoplication measuring approximately [X] cm was constructed with [number] interrupted [suture] sutures [over a [X]-Fr bougie]. The wrap was centered on the distal esophagus and inspected for proper orientation without constriction.

With Toupet Fundoplication

A posterior partial fundoplication was selected because of [preoperative dysphagia / impaired esophageal motility / patient-specific considerations]. The fundus was passed posterior to the esophagus without tension and secured to the right and left sides of the distal esophagus with [number] interrupted [suture] sutures, creating an approximately 270-degree wrap. The wrap was additionally anchored to the [right / left / both] crura as performed, leaving the anterior esophagus uncovered.

With Mesh Reinforcement

Mesh reinforcement was selected because of [attenuated crural tissue / residual tension after primary closure / recurrent hiatal defect / other]. A [biologic / absorbable synthetic / permanent synthetic] mesh measuring [X × Y] cm was configured as a [U-shaped posterior onlay / other] and secured with [sutures / fixation device / adhesive]. The mesh configuration, fixation points, and relationship to the esophagus were inspected and documented as [***].

Gastropexy Without Fundoplication

Fundoplication was omitted because of [emergency presentation / cardiopulmonary instability / severe esophageal dysmotility / patient-specific considerations]. After hiatal closure, the stomach was secured to the [left hemidiaphragm / anterior abdominal wall] with [number] interrupted [suture] gastropexy sutures. [A gastrostomy tube was placed for fixation, decompression, or feeding as separately documented.] The gastroesophageal junction and stomach remained below the diaphragm without twisting or obstruction.

Short Esophagus / Possible Lengthening Procedure

After complete mediastinal mobilization, the gastroesophageal junction rested approximately [X] cm below the hiatus with [persistent axial tension / inadequate intraabdominal length]. A short esophagus was documented. [No lengthening procedure was performed because *** / A Collis-type lengthening procedure was performed and is separately documented.]

Charting Tips

Document the hiatal-hernia type, dimensions, position of the gastroesophageal junction, every herniated organ, and any volvulus or tissue ischemia.
State whether the hernia sac was reduced, partially excised, or excised and record any pleural entry or injury encountered during mediastinal dissection.
Record the measured position of the gastroesophageal junction below the hiatus after mobilization and whether it rested there without traction.
Describe crural tissue quality, the location and pattern of closure, suture material, pledget use, and how the final opening was assessed for constriction.
Document fundoplication, gastropexy, mesh reinforcement, calibration, and intraoperative endoscopy only when performed.
If mesh was used, record the rationale, material, size, configuration, fixation, and relationship to the esophagus.
If a short esophagus was suspected, document the finding after complete mobilization and whether a lengthening procedure was deferred or separately performed.