Hiatal hernia

• Type I: sliding
• Type II: paraesophageal
• Type III: mixed (sliding and paraesophageal)
• Type IV: additional abdominal organ herniation (e.g., omentum, colon, spleen)
• Large (giant) paraesophageal hernia: >30% of stomach is intrathoracic

Short esophagus

• < 2-3 cm tension-free intra-abdominal esophagus after complete mediastinal mobilization

Surgical Principles

• Complete mediastinal sac reduction
• Evaluation of esophageal length and appropriate use of esophageal lengthening procedures
• Tension-free hiatal closure
• Anti-reflux procedure

Laparoscopic Steps

1. Incise the hernia sac anteriorly, leaving peritoneal coverage on the crura
2. Extensive mediastinal sac and esophageal dissection
3. Hernia sac reduction from the chest
4. Dissection of fat pad off the anterior stomach along lesser curve for identification of the gastroesophageal junction and evaluation of intra-abdominal esophageal length
5. Collis-wedge gastroplasty (if < 2-3 cm intraabdominal esophagus) over a 48- to 54-Fr dilator
6. Nissen fundoplication over a 52- to 54-Fr dilator

Follow-up

• Annual symptom assessment using validated questionnaire annually for 5 years
• Anatomic evaluation (barium esophagram) every year for 5 years
• Endoscopic evaluation within 1 year of surgery for patients with preoperative esophagitis, stricture, or Barrett’s esophagus
• Persistent or progressive esophageal mucosal abnormalities without anatomic recurrence should be evaluated further