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.
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