A new technique for treating hiatal hernia with gastroesophageal reflux disease: the laparoscopic total left-side surgical approach

Abstract

Introduction: Although the traditional bilateral surgical approach to treat hiatal hernia (HH) with gastroesophageal reflux disease (GERD) can provide local protection of the vagus nerve, the integrity of the entire vagus nerve cannot be evaluated. Therefore, we developed and described the total left-side surgical approach (TLSA), which theoretically reduces injury to the vagus nerve, and described the detailed surgical procedure.

Methods: Initially, we performed a cadaver study to explore the characteristics of the vagus nerve. Then, we prospectively evaluated the TLSA in 5 patients with HH and GERD between June 2020 and September 2020. Demographic characteristics, surgical parameters, perioperative outcomes, and follow-up findings were analyzed.

Results: The TLSA was successfully used in five patients (40-64 years old), and no major complications were noted. The median total operative time was 114 min, median blood loss was 50 mL, and median postoperative hospital stay was 3.8 days. Gastrointestinal function recovered within 4 days of surgery in all the patients. The 6-month follow-up gastroscopy examination showed well-established gastroesophageal flap valves. Compared with the baseline results, the 6-month follow-up results showed lower values for the total GerdQ score (12.4 vs. 6.2) and the total esophageal acid exposure time (3.48% vs. 0.38%). Based on the European Organization for Research and Treatment of Cancer quality of life questionnaire-stomach module 52 results, the incidence of dysphagia and flatulence decreased over time after the TLSA.

Conclusions: The TLSA provides a clear and broad surgical field, less trauma, and rapid recovery; moreover, it is technically simple. Although our results suggest that the TLSA provides safety and short-term efficacy and is feasible for patients with HH and GERD, long-term results from a larger clinical trial are needed to validate these findings. Trial registration ChiCTR2000034028, registration date is June 21, 2020. The study was registered prospectively.

Keywords: Fundoplication; Gastroesophageal reflux disease; Hiatal hernia; Total left-side surgical approach; Vagus nerve.

Fig. 1

Surgeon position. The surgeon stands on the patient’s left side throughout the surgery, whereas the first assistant stands on the patient’s right side and the second assistant stands between the patient’s legs and manipulates the laparoscope. The picture depicted in Fig. 1 was my own based on the actual scenario of surgery

Fig. 2

Puncture port placement. a A 12-mm trocar is inserted through a transverse incision, 1.0 cm above the umbilicus to establish the pneumoperitoneum and insert the laparoscope. b A left anterior axillary subcostal incision is created to accommodate the primary 12-mm trocar. c A left midclavicular horizontal incision is made 2.0 cm above the umbilicus to accommodate an auxiliary 5-mm trocar. d A right midclavicular horizontal incision is made 2.0 cm above the umbilicus to accommodate a 12-mm trocar for the assistant’s instruments. e A right anterior axillary subcostal incision is made to accommodate a 5-mm trocar. f An incision is made 2.0 cm below the xiphoid process to accommodate a 5-mm trocar that is used to expose the hiatal region. The picture depicted in Fig. 2 was my own based on the actual scenario of surgery

Fig. 3

Operative technique. a On the stomach’s greater curvature, the gastrocolic ligament is incised along the avascular area between the left and right gastric omentum vessels, and the gastric fundus is lifted vertically toward the cardia to protect the vagus nerve. b The cardia, lower esophagus, and diaphragm are exposed, and the confluence of the left and right crus of the diaphragm is revealed. The retroperitoneum is incised at the left and right crus of the diaphragm, and the lower esophagus is dissociated for approximately 3–5 cm. The gastric fundus and the posterior wall of the esophagus are fully dissociated from the upper spleen. c Non-absorbable intermittent sutures are used at the left and right crus of the diaphragm to reconstruct the esophageal hiatus (diameter: approximately 1.5 cm). d The surgeon inserts the mesh and fixes it to the crus of the diaphragm with staples if the HH size is > 5 cm or the diaphragm on both sides of the defect is weak. e A small incision (approximately 2–3 cm) is made above the bifurcation of the anterior vagal trunk and the hepatic branch of the vagus nerve. This region is the avascular area of the lesser omentum. f The fundus of the stomach is rotated around the posterior aspect of the abdominal esophagus to the right anterior aspect of the esophagus (using non-absorbable sutures for 2 or 3 stitches intermittently) and then fixed to the right crus of the diaphragm and the right side of the esophagus. The left side of the gastric fundus is also sutured to the anterior esophagus and the left crus of the diaphragm, which avoids vagus nerve injury. Finally, the surgeon completes the fundoplication

Fig. 4

Anatomical characteristics of the anterior vagal trunk. a The anterior vagal trunk travels from the upper left to the lower right of the anterior esophageal wall (red dotted line). b It is located between the muscular layer and the peritoneum of the anterior abdominal esophageal wall, where it is closely adhered to the muscular layer of the esophagus (red dotted line)

Fig. 5

Anatomical characteristics of the posterior vagal trunk. a The posterior vagal trunk travels through the loose tissue outside the muscular layer of the right posterior wall of the abdominal esophagus (red dotted line). b The posterior vagal trunk produces nerve branches below the cardia (red dotted line) and c the celiac branch and posterior gastric branch (red dotted line)

Fig. 6

Comparing the findings from gastroscopy before surgery and 6 months after surgery. a Preoperative gastroscopy reveals a large hernia sac (red dotted circle) protruding into the chest. b A schematic diagram of the hiatal hernia. c The hernia sac disappeared after Nissen fundoplication, and the gastric fundus flap was visible (red dotted line). d A schematic diagram showing the results of the Nissen fundoplication. e Gastroscopy suggesting that the patient had severe esophagitis prior to the TLSA. f Gastroscopic examination 6 months after surgery indicating that the esophagitis has improved. The picture depicted in Fig. 6 was my own based on the actual gastroscopic photograph