Transthoracic Hiatal Hernia Repair

Abstract

With the advent of laparoscopic and robotic surgery, transthoracic repair of hiatal hernia has become less common. In certain situations, such as multiple prior transabdominal repairs or otherwise hostile abdomen, a transthoracic approach can be helpful. Indications for surgery mirror those for candidates for transabdominal hiatal hernia repair; preoperative evaluation consists of history, physical examination, barium swallow, CT scan, pulmonary function testing, and, if possible, manometry and pH study. Transthoracic repair is generally performed through a left 6th or 7th intercostal space thoracotomy. The hernia sac is mobilized and reduced along with the herniating organs, and the diaphragmatic crura is tightened around an endoscope or bougie. A Collis gastroplasty is performed if there is inadequate esophageal length, and a Belsey fundoplication encompassing 270 degrees of the stomach is performed. Postoperative care involves multimodality pain management, prevention of vomiting and retching, barium swallow to establish a baseline anatomy following repair, and cautious advancement of diet.