Techniques and pitfalls of laparoscopic paraesophageal hernia repair in severe kyphoscoliosis patients.

BACKGROUND: Increasing evidence suggests that kyphoscoliosis may play a role in the pathophysiology of paraesophageal hernia development. The presence of severe kyphoscoliosis not only increases the incidence of paraesophageal hernia but also increases the risk of hiatal hernia (HH) repair. Moreover, the technical skills and the pitfalls of laparoscopic repair of HH in this special condition have yet been described.
METHODS: The technical skills, experience and pitfalls of laparoscopic paraesophageal hernia repair in severe kyphoscoliosis patients were described. These include perioperative care of patients' pulmonary function, patients' operating position and trocar placement, and the key steps and risks of laparoscopic HH repair in this special condition.
RESULTS: Paraesophageal HHs were successfully laparoscopically repaired, and prolonged hospital stay was due to post-operative pulmonary complications.
CONCLUSION: These techniques are essential to minimise the perioperative complications in laparoscopic paraesophageal hernia repair in severe kyphoscoliosis patients, and great pulmonary care is required in these patients.

INTRODUCTION

Although the precise causes of paraesophageal hiatal hernia (HH) are still unknown, a number of factors have been suggested, including trauma, iatrogenic reasons, increased abdominal pressure and crual diaphragm muscular degeneration.[12] Interestingly, several lines of evidence have indicated that there is a clinical association between HH and kyphoscoliosis.[3456] Although a definite cause-effect relationship is difficult to prove, it has been postulated that the marked curvature of the thoracic and/or lumbar spine caused by kyphoscoliosis would lead to lengthening and laxity of the diaphragmatic crura and subsequently result in widening and disruption of the phrenoesophageal attachments, which predispose to the formation of HH over time.[57] Both HH and kyphoscoliosis are common in patients over the fifth decade of life, and furthermore, severe kyphoscoliosis can cause significant thoracic and abdominal deformation, not only impair pulmonary function, but also restrict abdominal space, which significantly increases the morbidity and mortality during the surgical repair of HHs. Until now, there are few data available to specifically address the skills and pitfalls of HH repair; thus, in the present study, we report our experience of laparoscopic HH repair in the condition of severe kyphoscoliosis in three severe adult cases, and especially, the key steps are described in the present report in the typical series.

PRE-OPERATIVE PREPARATION

A thorough pre-operative evaluation was performed including evaluation of possible comorbidities of the patients, especially pulmonary function, cardiac function, nutritional status and/or blood-gas analysis, and the bowel preparation was also performed 1 day before the operation. Three severe kyphoscoliosis patients with paraesophageal hernias were included in the present study. The first patient was a 57-year-old female with the diagnosis of HH and severe scoliosis [Figure 1a]. The chest X-ray, upper gastrointestinal contrast study and computed tomography (CT) scan showed a paraesophageal hernia containing the stomach and the marked curvature of the spine [Figure 1b]. The second patient, a 77-year-old female, also had severe kyphosis for >10 years [Figure 2a]. The upper gastrointestinal series study and CT scan revealed the large paraesophageal hernia containing the stomach inside the mediastinum and severe scoliosis which caused significant thoracic deformation [Figure 2b], and the aorta was distorted and distracted to the right side. The third case is a 78-year-old female, she lost a significant amount of weight and her weight was only 40 kg [Figure 3a]. Therefore, she received total enteral nutrition (TPN) for the past 3 months in a local community hospital. The upper gastrointestinal series and CT scan confirmed the paraesophageal hernia which appeared to contain the transverse colon in the right hemithorax and the first part of duodenum in the mediastinum and severe kyphosis. The hernia was associated with compression of local structures [Figure 3b].

Figure 1

(a) Patient 1 showing severe scoliosis. (b) The upper gastrointestinal series demonstrated the giant paraesophageal hernia containing the stomach and marked curvature of the spine

Figure 2

(a) Patient 2 showing severe kyphosis. (b) Computed tomography scan revealed the giant paraesophageal herniation and cardiovascular distortion, especially the aorta was pushed to the right side markedly

Figure 3

(a) The malnutrition status of patient with kyphosis. (b) The computed tomography scan showing marked curvature of the spine

POSITIONING OF PATIENT AND PORTS

All patients underwent elective laparoscopic HH repair in a standardised split-leg, 30° and supine reverse Trendelenburg position, with a nasogastric tube and Foley catheter placed before surgery, with a surgeon situated between the patient's legs. A urethral catheter was placed.

A key point is that a higher position of the camera port is needed. For establishment of pneumoperitoneum, the first 10-mm trocar was placed 2 cm above the umbilicus and used for the camera port. Another two trocars were placed on the left (5 mm) or right (10 mm) at the mid-clavicular line just inferior to the lower costal border, equidistant apart. The fourth one was 5-mm trocar placed in the left one below the costal margin at the post-calvicular line, and the fifth 5mm one was placed in the right lower quadrant at the level of the umbilicus.

OPERATIVE STEPS

Key steps of laparoscopic hiatal hernia repair

Essential to divide the short gastric vessels

The first crucial step was to divide the short gastric vessels, till the left side of the oesophagus, and freed the spleen away from the fundus of the stomach. The hernia sac was incised at its junction with the left crura and continued in a circular manner around the oesophageal hiatus and carefully dissected circumferentially off its mediastinal attachments until the gastroesophageal junction was mobilised at least 3 cm below the level of the diaphragm. The complete dissection of the hernia sac was on the surgeon's discretion. The hernia sacs in the first and second patients were fully excised without complication. While in the third patient, the hernia sac was only partially excised to avoid the unacceptably high risk of damage to the mediastinal structures.

Defect closure and non-traumatic mesh fixation techniques

The diaphragmatic crura defect was closed primarily by approximating the left and right crura with a 3-0 barbed suture (V-Loc™180, Covidien™, USA) and then over-sutured with 2-0 non-absorbable sutures [Figure 4a and b], and to reinforce the closure, a non-absorbable mesh composite mesh (7 cm × 7 cm, Surgimesh® XB, La Talaudiere, France) was used, the mesh was fixed with non-absorbable sutures and cyanoacrylate glue (Beijing Compont Medical Devices Co., Ltd.) in a non-traumatic fashion [Figure 4c] and no tack was used for mesh fixation in this condition. At last, a fundoplication (180 or 360) was created.

Figure 4

(a) The giant hiatus hernia, note the distorted aorta was along the right crura of the diaphragm. (b) The posterior hiatal closure was performed. (c) The hiatal hernia was reinforced with composite mesh which was fixed with suture and glue

There were no perioperative complications for the first two patients. While the third operation was very difficult due to the extremely restricted abdominal space and distorted anatomy caused by kyphosis, unfortunately, the spleen was injured due to poor exposure, the bleeding was difficult to control and the procedure was converted temporarily to open for splenectomy via a 10-cm upper abdominal incision. After splenectomy, the incision was closed and the hiatal repair was accomplished by laparoscopic procedure again.

Post-operative care and outcome

The first two patients recovered very well, they had no peri- and post-operative complications and the post-operative hospital stay was 4 days and 7 days, respectively. While the third patient developed hydrothorax, pulmonary atelectasis, urinary tract infection and wound infection, she had a prolonged stay in hospital and recovered and discharged at 37th day post-operatively.

DISCUSSION

Both HH and kyphoscoliosis are common in older individuals,[8] and the past evidence suggested that these two abnormalities were pathologically related.[910] Anatomically, the spine and the oesophagus are directly attached and closely related in the posterior mediastinum; it is conceivable that disruption of the normal physiologic alignment and the distorted position of the spine can result in crural widening and disruption of the phrenoesophageal attachments and predispose to formation of a HH.[7] Of clinical significance, the deformity of the spine not only contributes to the development of HH theoretically but also poses great danger for laparoscopic hiatal repair. As seen in Figure 4a, the aorta became more superficial and right sided, which renders increased hazard for both hiatus dissection and mesh fixation, and the tack fixation would be dangerous to the aorta which closely behind the right crura. Therefore, we strongly recommend fixing the mesh with careful suture and glue and tacks should not be used in this situation.

Furthermore, patients with kyphoscoliosis are affected with a reduced intra-abdominal volume; thus, the operating space for laparoscopic manipulation may be reduced and lead to spleen injury and subsequent splenectomy. It has been reported that higher conversion rate was associated with scoliosis due to either poor exposure or bleeding;[3] thus, to improve the surgical manipulating convenience, we suggested that the optical trocar should be placed at a higher position and at least 2 cm above the umbilicus, which would provide a better view of the hiatus of spleen site.

Although the short vessels do not need to be divided routinely in laparoscopic HH repair, we recommend dividing the short vessels in patients of kyphoscoliosis at an early step, which can offer an easier access and better view for HH repair, thus avoid any injuries to the spleen and provide better exposure of structures of hiatus.

Severe thoracic kyphoscoliosis can predispose to other systemic manifestations as well, including restrictive pulmonary disease patterns, decreased total lung and vital capacity and reduced chest wall compliance. Therefore, patient selection and pre-operative evaluation are of paramount in this population. A thorough assessment of pulmonary function, as well as complete radiographic examination, should be performed on each patient, and the pulmonary function test information is useful in patients with kyphoscoliosis to stratify the risk of post-operative pulmonary insufficiency and special attention should be paid to increased pulmonary morbidity, especially in post-operative management of these patients; the patient's pulmonary hygiene is encouraged and ambulation is initiated on the 1st post-operative day.

CONCLUSION

HH repair in severe kyphoscoliosis patient is a challenging procedure due to the distorted anatomy, restricted abdominal space and increased perioperative pulmonary morbidity; thus, special techniques should be followed and special attention is required in perioperative managing these patients.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.