Paraesophageal Hernia Repair

Esophageal hernia repair is used for the surgical treatment of congenital diaphragmatic hernia. The basic factor in the pathogenesis of esophageal hiatal hernia is the congenital defect left in the embryonic stage during the complex process of the formation of the diaphragm. Hiatal hernia, which occurs in the esophageal hiatus, is usually divided into: 1 esophageal hiatus with a short esophagus, such a cardia in the thoracic cavity; 2 paraesophageal hernia, the esophageal position is normal, and part The stomach enters the thoracic cavity from the esophagus and often has a twist; 3 sliding hiatal hernia, the lower end of the esophagus is not fixed, and the cardia and part of the stomach protrude into the thoracic cavity. In addition to the principle of hernia repair, esophageal hernia repair should also pay attention to restore the function of the cardia and correct gastric reflux. Based on different views on the mechanism of closing the cardia, the surgical methods vary and are still being improved. Some people focused on placing the cardia in the abdomen and fixed it; some emphasized the reconstruction of the esophagus-gastric angle (His angle); some people used the repair of the hole, reconstruction of the esophagus-gastric angle, vagus nerve cutting and pyloric formation; Bottom folding (Nissen surgery). Treatment of diseases: hiatal hernia Indication Small and no obvious symptoms or infants under 1 year old, most of them can be cured by non-surgical treatment, no surgery is required. The hole is larger, and 1/3 of the stomach enters the chest; in addition to the stomach, there are organs such as the small intestine invaders; there are obvious symptoms such as vomiting, aspiration, pneumonia, anemia, reflux esophagitis causing stenosis, affecting growth Developmental sick children should be treated surgically. Surgical procedure 1, transthoracic surgery (1) Incision: The right lateral position, the left 7th or 8th intercostal incision into the chest. (2) reveal the hernia sac; cut off the lower lung ligament, push the lung up, you can see the hiatus in the posterior mediastinum. The mediastinal pleura is cut longitudinally in the triangle formed by the heart, the thoracic aorta and the transverse iliac crest. If necessary, the lower end of the incision can be enlarged and cut laterally forward and backward to fully reveal the deep sac. Do not cut the sac. (3) Free esophagus and intrathoracic gastric vesicle: free the normal part of the lower end of the esophagus, which is pulled around with a rubber sheet or a gauze strip, and the sputum is separated downward and the gastric sac is inserted into the chest. The upper end of the esophagus generally only needs to be free under the aortic arch, but if the esophagus is too short, the cardia is difficult to retract within the abdomen, then the esophagus must flow above the aortic arch. In the foregoing operations, care should be taken to avoid damage to the contralateral pleura, vagus nerve, recurrent laryngeal nerve, and thoracic duct. (4) also to the contents and treatment of the sac: for the mild short-term esophagus only need to cut the diaphragm from the hole to the posterior aspect, free of the hole, the stomach is also within the abdomen, the lower end of the esophagus and the edge of the hole are sutured and fixed. When the esophagus is short and the cardia is not easy to reset, the hole should be displaced and lifted. The original hole is cut to the highest point of the center, so that the cardia can be re-intestinal and the diaphragm can be repaired behind the esophagus. The lower end of the esophagus is fixed with the new fissure hole. If the esophageal hiatus is smaller, the sac can not be cut, and only the circular suture can be folded. Be careful not to damage the stomach wall and vagus nerve under the sac. If the esophageal hiatus hernia sac is larger, the sac should be cut open, and the stomach should be retracted. The excess sac is cut off and the edge of the sac is intermittently sutured. When the stomach in the esophageal hiatus sac is still difficult, you can make another mouth on the posterolateral side of the diaphragm. The stomach is gently retracted through the incision, which is convenient for suturing the sac. The diaphragm and mediastinal pleura are then sutured. In the sliding esophageal hiatus hernia, the esophageal ligament has been elongated, which must be shortened and the esophageal attachment edge of the ligament is fixed under the diaphragm. The specific method is: an incision is made at the junction of the lateral muscle of the diaphragm and the central malleolus. The left thumb and the middle finger of the operator enter the abdominal cavity through the incision, and extend along the stomach wall to the top of the hernia sac, that is, the attachment point of the hernia sac at the lower end of the esophagus. The sac was cut open at a level of 2 cm from this point, and a 2 cm wide sac edge was attached around the lower end of the esophagus. The lifting gauze at the lower end of the esophagus is pulled from the transverse incision so that the cardia is inserted into the abdomen through the slit. The sac of the sac of the esophagus is interrupted and sutured under the diaphragm. This has eliminated the normal position of the sac ligament. (5) suture sputum: short-term esophagus should be sutured to the periphery of the hiatus and the lower end of the esophagus. For the esophageal paralysis and sliding type iliac crest, the loose diaphragmatic foot should be sutured behind the esophagus to make it elastic and appropriate. Generally, it is better to leave the stomach tube in the esophagus after suturing. (6) The transverse incision is sutured with silk suture. If the tension is too large, the phrenic nerve can be closed, and then the thoracic closed drainage can be performed. The layers of the chest wall are sutured layer by layer. 2, abdominal surgery Nissen surgery (stomach fold). (1) Incision: median incision in the upper abdomen or median incision in the left side. (2) After the laparotomy, the stomach is pulled downward. To fully reveal the surgical field, the left triangular ligament of the liver can be cut open, and the left lobe of the liver can be pulled to the right to reveal the cardia. The holes are separated, and the fundus that has been inserted into the chest cavity is also placed in the abdominal cavity. Loop the lower end of the esophagus and pull it down. The tendon of the diaphragm is sutured behind the esophagus to repair the fistula. (3) The fundus is turned over, wrapped around the lower end of the esophagus 3 to 4 cm long, and the stomach bottom and the anterior wall of the stomach are sutured 3 to 4 needles in front of the esophagus. When suturing, attention should be paid to the proper tightness to prevent too narrow, that is, to complete the fundus fold. In order to effectively fix the stomach and not shift it to the thoracic cavity, it is advocated to suture the peritoneum and rectus abdominis posterior sheath of the small anterior wall of the stomach and the corresponding part of the anterior abdominal wall, and suture the lower part of the fundus and the diaphragm. . complication 1. The folding and suturing is tight and the passage is blocked. 2. The esophagus slips off from the package. 3. The fold is broken into the posterior mediastinum.