Hiatus Hernia

Acquired form of diaphragmatic hernia

Types:

1. Sliding: GOJ slides through the oesophageal opening of the diaphragm
2. Rolling / paraoesophageal: GOJ remains in position but area of stomachad peritoneum rolls up alongside oesophagus into thorax

Gastro-Oesophageal Reflux Disease

Management

1. History
   • Burning pain
2. Examination
3. Investigations
   • Upper GI endoscopy + biopsy to detect oesophagitis and Barrett's oesophagus
   • 24h pH manometry
4. Treatment
   • Lifestyle changes: weight loss, avoid alcohol and smoking, avoid large meals at night
   • Medical: antacids, H2 antagonists, PPIs
   • Surgery in: severe persistent regurgitation, severe reflux symptoms, patient choice

Nissen Fundoplication

Other options - Belsey Mark IV: fundoplication through thoracotomy - Hill gastropexy (securing cardia to pre-aortic fascia

1. Laparscopic / Midline incision
2. GA + elevate head end of table
3. Create pneumoperitoneum / access oesophagus
   • Divide lesser omentum
   • Retract right lobe of liver
   • Dissect oesophageal hiatus
4. Repair crural defect
   • Identify crura
   • Dissect 3-4cm of abdominal oesophagus and mobilise
   • Retract oesophagus to right
   • Repair crural defect with interrupted non-absorbable sutures
5. Free fundus and greater curvature
   • Divide short gastric vessels
   • Freed fundus passed behind and then to the left of the oesophagus
6. Fundoplicate
   • Fundal wrap held with 3 interrupted non-absorbable sutures, taking bites of both fundal folds and the oesophagus
7. Finish
   • Irrigate operative field + ensure haemostasis
   • Close fascial defects