Name: laparoscopic repair of para-esophageal hernia using absorbable biosynthetic mesh
Uploaded: 2021-09-11T13:00:00.000+00:00
Duration: 10 min 52 s
Description: Watch this Scientific Journal Video about Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh at JoVE.com

The authors have no acknowledgements.

The protocol follows the guidelines of the authors&#8217; institution&#8217;s human research ethics committee (South-Western Health District).
1. Pre-operative preparation
<ol>
	<li>Place the patient on low calorie high protein nutritional diet for a week to reduce the liver size and facilitate improved access to the hiatus hernia.</li>
	<li>Under general anesthesia, place the patient in lithotomy and reverse Trendelenburg position.</li>
	<li>Intra-operatively, prescribe first-generation cephalosporin prophylactic (2 g) intravenous antibiotic and anticoagulation for deep vein thrombosis prophylaxis.</li>
</ol>
2. Surgery
<ol>
	<li>Prepare the sterile field by shaving the patient&#8217;s abdomen, applying antiseptic solution to the skin and draping the patient. Ensure that the first surgeon stands between the patient&#8217;s legs and the assistant is on the left side.</li>
	<li>Establish Pneumoperitoneum of 12 mm Hg via a left subcostal Veress needle at Palmer&#8217;s point9 (3 cm below the subcostal margin in the left mid-clavicular line). Using a direct bladeless optical access entry system, insert the ports which is supra-umbilical, one hand-span from the costal margin and to the left of the midline, for the camera.</li>
	<li>Elevate the left lobe of the liver with a Nathanson liver retractor through a small left para-xiphoid incision.</li>
	<li>Place two further 5 mm ports under direct vision alongside the camera port: one at the level of the right mid-clavicular line, the second port on the left anterior axillary line. Insert a 10 mm port that is more cephalad at the left mid-clavicular line to create an ideal working triangulation. 
	NOTE: See Supplementary Figure 1 for port placement.</li>
	<li>At this stage ensure that most of the stomach will be herniating into the mediastinum. Therefore, pull the incarcerated stomach back into the abdominal cavity with continuous traction from the assistant to view the gastro-esophageal junction.</li>
	<li>Enter the lesser curvature at the level of the pars flaccida of the gastrohepatic ligament, and progressively dissect, reduce and excise the hernia sac using cauterization. This will lead to the gradual exposure of both diaphragmatic crura. This is made of the inferior vena cava and the caudate lobe of the liver in relation to the right crus.</li>
	<li>Mobilize the esophagus circumferentially by dividing all the congenital peri-esophageal adhesions within the hiatus. Continue mobilizing the hiatus hernia off the bilateral crura to assist in retracting the hernia sac into the abdominal cavity. Identify and preserve the vagus nerves and both pleurae.</li>
	<li>Create a window posteriorly between the esophagus and thoracic aorta and place a tape around the distal esophagus to allow gentle traction.</li>
	<li>Mobilize the distal esophagus proximally (&#8805;10 cm distance), until there is adequate intra-abdominal esophageal length (3-4 cm) and so the esophagus lies free of tension.</li>
	<li>Approximate the diaphragmatic crura with 3 or 4 interrupted 1.0 non-absorbable braided sutures and reinforce the repair with a pre-shaped biosynthetic mesh that is introduced behind the esophagus in an onlay fashion. 
	NOTE: The right edge of the mesh should slide under the caudate lobe of the liver. If necessary, divide the left triangular ligament to accommodate the mesh. No pledgets are required if the quality and the tension of the crura is adequate. The extent of the crural closure should not cause narrowing or compression on the lower esophagus. A rough guide to adequate closure is being able to pass a grasper through the remaining gap.</li>
	<li>Secure the biosynthetic mesh with 4 mL of fibrin glue.</li>
	<li>Perform a modified 180&#730; anterior Dor fundoplication using 2.0 non-absorbable braided sutures by suturing the gastric fundus to the left crus, then sequentially fixing the folded greater curvature of the stomach anteriorly to the diaphragm, and all the way to the proximal right crus. Four sutures are usually required. Incorporate the mesh into the first suture. Take care not to injure the pericardium during the fundoplication. A bougie is not used.</li>
	<li>Insert a closed-suction drain.</li>
	<li>Close skin with subcuticular 3.0 synthetic, absorbable and monofilament sutures.</li>
</ol>
3. Post-operative procedures
<ol>
	<li>Post-operatively, elevate the patient&#8217;s head to 30&#730; to avoid aspiration.</li>
	<li>Perform early chest X-ray in recovery to exclude possible pneumothorax or atelectasis.</li>
	<li>Commence the patient on clear fluids on day one. Give regular anti-emetics for the first 24 h. Commence the patient on daily anticoagulation for deep vein thrombosis (DVT) prevention as per the hospital protocol.</li>
	<li>Commence the patient on puree diet on day two. Remove the drain after 24 to 48 hours.</li>
	<li>Continue puree diet for two weeks. Afterwards, place the patient on to a more solid but soft diet for three weeks.</li>
	<li>Continue DVT prophylaxis until the patient goes home. Extended course can be given at the surgeon&#8217;s discretion if deemed necessary.</li>
	<li>Follow-up the patient at 2 and 6 weeks for routine surgical review.</li>
	<li>Perform repeat gastroscopy at 4,12 and 24-months post-operative.</li>
</ol>

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The authors have nothing to disclose.

The key steps in para-esophageal hernia repair include port placement, total excision of the hernia sac, intra-abdominal esophageal lengthening, identification of both vagus nerves, atraumatic mesh reinforcement of the crus, and anterior fundoplication with gastroplasty.
This protocol highlights a 4-port method (one camera, three working ports) which uses only one assistant. Safe insufflation is achieved through a Veress needle inserted at Palmer&#8217;s point. An optical bladeless access syst...

The most recent meta-analysis review on para-esophageal hernia repair concluded that mesh reinforcement was superior and was associated with lower recurrence rates compared to the suture repair1. However, the preferred type of mesh remains controversial due to the study heterogeneity. Some included in the review had inconsistent definitions not only of para-esophageal hernias (which were either determined pre-operatively or intra-operatively) or hernia recurrences (which were based, either on symptoms or investigations), but also unspecified loss to follow-up. This manuscript highlights successful repair of a large hiatus hernia using biosynthetic mesh.
The most common biosynthetic mesh used is composed of 67% polyglycolic acid and 33% trimethylene carbonate. This prosthesis is gradually absorbed over 6 months and is replaced by the vascularized soft tissue and collagen. This biosynthetic mesh has been studied in 395 patients and in this large study, 16.1% of them experienced recurrent symptoms at 24 months (range, 2-69 months) and 7.3% had objective recurrence2. Only one patient had a major post-operative complication (esophageal stenosis) that required percutaneous endoscopic gastrostomy tube insertion and subsequently, re-operation with no recurrence at 44 months. Similar smaller studies reported symptom recurrence rates ranging from 0%-9%, objective recurrence rates 0.9%-25%, and re-operations ranging from 0%-10%4,5,6,7,8. None of the studies reported mesh-related complications.
The protocol detailed below was performed on a 68-year-old female who presented with a one-year history of severe reflux symptoms unresponsive to medical treatment and iron deficiency anemia, in the setting of previous Helicobacter pylori gastritis and NSAID-induced gastric ulcer. Pre-operative gastroscopy demonstrated Cameron&#39;s ulcers, large linear erosions in the gastric body and a 10 cm rolling hiatus hernia (compared to 4 cm in the previous gastroscopy one year earlier). Chest CT-scan confirmed the diagnosis of intra-thoracic para-esophageal hernia.

<table><tbody><tr><td>1.0 non-absorbable suture</td><td></td><td></td><td></td></tr><tr><td>10 mm port</td><td></td><td></td><td></td></tr><tr><td>3.0 absorbable suture</td><td></td><td></td><td></td></tr><tr><td>5mm port</td><td></td><td></td><td></td></tr><tr><td>Biosynthetic mesh</td><td>GORE BIO-A</td><td></td><td></td></tr><tr><td>Bladeless optical access entry system</td><td>Kii</td><td></td><td></td></tr><tr><td>Drain&amp;nbsp;</td><td></td><td></td><td></td></tr><tr><td>Fibrin glue</td><td>Tiseel</td><td></td><td></td></tr><tr><td>Laparoscopic grasper</td><td>Ethicon</td><td></td><td></td></tr><tr><td>Laparoscopic harmonic&amp;nbsp; scalpel</td><td>Ethicon</td><td></td><td></td></tr><tr><td>Nathan liver retractor</td><td></td><td></td><td></td></tr><tr><td>Sling</td><td></td><td></td><td></td></tr><tr><td>Veress needle</td><td></td><td></td><td></td></tr></tbody></table>

laparoscopic repair of para-esophageal hernia using absorbable biosynthetic mesh

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been associated with lesser hernia recurrence when compared to the primary suture repair. The type of mesh that is most appropriate is still debatable. Synthetic and biosynthetic materials have been studied in the literature. It is well documented that a synthetic mesh is associated with esophageal erosion and migration into the stomach. Though there are limited long-term data on biosynthetic mesh, the short-term results are excellent and promising.
This paper illustrates how a biosynthetic prosthesis can be safely used with fibrin glue fixation and anterior Dor fundoplication to repair any para-esophageal defect. The absorbable biosynthetic mesh has been shown to produce good long-term patient satisfaction outcomes and low recurrence rates compared to conventional methods including repair with synthetic mesh. This technique also avoids the risk of esophageal erosion whilst strengthening the repair. Tacks that are still widely used to secure the mesh can be abandoned due to the associated risk of developing cardiac tamponade, or other disastrous consequences. This repair method, also, highlights how the prosthesis can be fashioned into a V-shape and easily placed in an onlay fashion behind the esophagus. The protocol demonstrates an alternative and safer method for mesh fixation using fibrin glue.

Post-operatively the patient remained symptom free. Routine gastroscopies at 4, 12 and 24&#160;months respectively showed that the cardio-esophageal junction remained at 38 cm from the dental arcade with no evidence of early recurrence or reflux esophagitis. There was mild gastritis of the antrum.
This technique has been performed in 32&#160;patients using&#160;absorbable biosynthetic mesh. Only one patient reported complication (Table 1).
<table border="1" fo:keep-togethe...

Watch this Scientific Journal Video about Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh at JoVE.com

Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Para-esophageal hernia repairs are challenging procedures and there is no consensus on the optimal approach to repair. Mesh reinforcement has been ...

laparoscopic-repair-para-esophageal-hernia-using-absorbable

Research

JoVE Journal

Medicine

5.2K Views.  Bankstown-Lidcombe Hospital. Presented here is a protocol of para-esophageal hernia repair. Use of absorbable biosynthetic mesh avoids the risk of erosion through the esophagus whilst reinforcing the repair. Glue fixation is preferred to avoid the risk of trauma such as bleeding or cardiac tamponade, which are associated with stitches or tacks.

Video: Laparoscopic Repair of Para-Esophageal Hernia Using Absorbable Biosynthetic Mesh

An Ivor Lewis Esophagectomy Designed to Minimize Anastomotic Complications and Optimize Conduit Function

We describe a novel esophagogastric anastomotic technique (&ldquo;side-to-side: staple line-on-staple line&rdquo;, STS) for intrathoracic anastomoses designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply. This technique aims to minimize the incidence of anastomotic leaks and strictures, which is a frequent source of morbidity and occasional mortality after esophagectomy. We analyze the results of this STS technique on 368 patients and compared outcomes to 112 patients who underwent esophagogastric anastomoses using an end-to-end stapler (EEA) over an 8-year time interval at our institution.
The STS technique involves aligning the remaining intrathoracic esophagus over the tip of the lesser curve staple line of a stomach tube, created as a replacement conduit for the esophagus. A linear stapling device cuts through and restaples the conduit staple line to the lateral wall of the esophagus in a side-to-side fashion. The open common lumen is then closed in two layers of sutures.
There was a total of 12 (3.8%) anastomotic leaks in patients who underwent STS esophagogastric anastomosis. Two of eight patients (25%) had anastomotic leaks after esophagectomy for end-stage achalasia as compared to a 2.8% leak rate (10/336) after esophagectomy for other conditions. Eighteen (5.2%) patients required a median of 2 dilatations for anastomotic stricture after STS anastomosis. Supplemental jejunostomy feedings were required in only 11.1% of patients undergoing STS anastomoses following hospital discharge. In contrast, patients undergoing EEA anastomoses demonstrated anastomotic leak and stricture rates of 16.1% and 14.3% respectively (p&lt;0.01). Time analysis of postoperative contrast studies following the STS technique typically demonstrated a straight/uniform diameter conduit with essentially complete contrast emptying into the small bowel within 3 minutes in 88.4% of patients.
The incidence of esophagogastric anastomotic leaks and strictures were extremely low using this novel anastomotic technique. Additionally we believe that based on time and qualitative analyses of postoperative contrast studies, this technique appears to optimize postoperative upper gastrointestinal tract function; however, further comparative studies are needed.

We describe a novel intrathoracic esophagogastric anastomotic technique designed to create a large diameter anastomosis while simultaneously maintaining conduit blood supply to minimize the incidence of anastomotic leaks and strictures. Construction and orientation of the stomach conduit designed to optimize upper gastrointestinal tract function is also described.

We describe a novel esophagogastric anastomotic technique (&ldquo;side-to-side: staple line-on-staple line&rdquo;, STS) for intrathoracic anastomoses ...

Cancer Research

Use of a Rat Model to Study Ventral Abdominal Hernia Repair

Ventral abdominal hernia is a relatively common clinical condition that sometimes requires herniorraphy (surgical repair). The repair of ventral abdominal hernia typically requires implantation of a material to serve as a mechanical bridge across the defect in the abdominal wall. Biomaterials, such as porcine small intestinal submucosa (SIS), also serve as a lattice for cell growth into the implant and can naturally incorporate into the host tissue. Development of such repair materials benefits from use of animal models in which experimental abdominal wall defects are easily created and are amenable to repair in a reproducible fashion. The method offered here describes surgical creation and repair of ventral abdominal hernia in a rat model. When SIS is used to repair an experimental ventral abdominal hernia in this model, it is rapidly incorporated into host tissue within 28 days of implantation. Histologically, incorporation of their implanted material into host tissue is characterized by a robust fibrovascular response. Future refinements and applications of the rat abdominal hernia model may likely involve diabetic and/or obese animals as a means to more closely mimic common co-morbidities of man.

This manuscript describes methods associated with creation and repair of a ventral abdominal wall defect (hernia). This model can be used to study repair strategies such as those that use implanted materials. In this manuscript, repair of the experimental hernia with porcine small intestinal submucosa is presented as an example.

Ventral abdominal hernia is a relatively common clinical condition that sometimes requires herniorraphy (surgical repair). The repair of ventral abdominal ...

Bioengineering

Tissue-Engineered Graft for Circumferential Esophageal Reconstruction in Rats

The use of biocompatible materials for circumferential esophageal reconstruction is a technically challenging task in rats and requires an optimal implant technique with nutritional support. Recently, there have been many attempts at esophageal tissue engineering, but the success rate has been limited due to difficulty in early epithelization in the special environment of peristalsis. Here, we developed an artificial esophagus that can improve the regeneration of the esophageal mucosa and muscle layers through a two-layered tubular scaffold, a mesenchymal stem cell-based bioreactor system, and a bypass feeding technique with modified gastrostomy. The scaffold is made of polyurethane (PU) nanofibers in a cylindrical shape with a three-dimensional (3D) printed polycaprolactone strand wrapped around the outer wall. Prior to transplantation, human-derived mesenchymal stem cells were seeded into the lumen of the scaffold, and bioreactor cultivation was performed to enhance cellular reactivity. We improved the graft survival rate by applying surgical anastomosis and covering the implanted prosthesis with a thyroid gland flap, followed by temporary nonoral gastrostomy feeding. These grafts were able to recapitulate the findings of initial epithelialization and muscle regeneration around the implanted sites, as demonstrated by histological analysis. In addition, increased elastin fibers and neovascularization were observed in the periphery of the graft. Therefore, this model presents a potential new technique for circumferential esophageal reconstruction.

Esophageal reconstruction is a challenging procedure, and development of a tissue-engineered esophagus that enables regeneration of esophageal mucosa and muscle and that can be implanted as an artificial graft is necessary. Here, we present our protocol to generate an artificial esophagus, including scaffold manufacturing, bioreactor cultivation, and various surgical techniques.

The use of biocompatible materials for circumferential esophageal reconstruction is a technically challenging task in rats and requires an optimal implant ...

A Case Series of Successful Abdominal Closure Utilizing a Novel Technique Combining a Mechanical Closure System with a Biologic Xenograft that Accelerates Wound Healing

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. The short and long-term consequences of living with a chronically open abdominal compartment include pulmonary, musculoskeletal, gastrointestinal, and emotional disability. The closure of catastrophic open abdomens presents a challenge to the surgeon. We present a technique utilizing a mechanical abdominal closure device in conjunction with biologic xenograft in closing complex open abdomens. This technique offers another option for definitive fascial closure and accelerated wound healing in this difficult patient population. The dynamic tissue system (DTS) is installed after control of original intraabdominal pathology. A porcine urinary bladder matrix (PUBM) is then placed in the subcutaneous space once fascial closure is achieved. Overall, primary myofascial closure was achieved in 100% of patients at a mean of 9.36 days.

Closure of catastrophic open abdominal wounds presents a challenge to the surgeon. We present a surgical technique utilizing a combination of mechanical and biologic xenograft closure systems in closing complex open abdominal wounds. This technique offers another option to the surgeon for definitive fascial closure and accelerated wound healing.

In the acute setting, once intra-abdominal injuries have been addressed, the next great hurdle is restoring a functional and intact abdominal compartment. ...

Application of Straight-needle, Three-tailed, Knot-free, Peritoneal Sutures in Laparoscopic Transabdominal Preperitoneal Hernia Repair

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is placed, the peritoneum must be resutured to avoid contact with the tissues and organs in the abdominal cavity. If the peritoneal suture time is too long, the operation and anesthesia time will be prolonged, increasing the burden on the patient. Moreover, improper suture methods cause serious consequences, such as intestinal obstruction and mesh infection.
The straight-needle suture method transforms the three-dimensional spatial configuration of the needle holder and the arc needle tip into a two-dimensional planar structure, which greatly reduces the difficulty of suturing. The three-tailed knot can be anchored at the beginning of the suture by its friction and button effect, which has an exact fixation effect. Thus, the suture does not easily slip, and the time to complete the suturing is shortened. Compared with the traditional suture method, the operator can suture the peritoneum more quickly, beginners can pass through the difficult learning curve faster, and skilled operators can also shorten the total operation time of TAPP to a certain extent. Thus, this suture method is extremely amenable to clinical application.

Here, we present a protocol to introduce a new peritoneal suture method. This method is called straight-needle, three-tailed, knot-free suture, and we will outline the manufacturing method and clinical application of this suture in detail.

Laparoscopic transabdominal preperitoneal hernia repair (TAPP) is one of the most widely used methods in inguinal hernia surgery. After the mesh is ...

Laparoscopic Non-Mesh Cerclage Pectopexy for Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore apical support for treating POP. Sacrocolpopexy and pectopexy are indicated for apical prolapse. Using a synthetic mesh in these techniques increases success by enhancing apical support. However, the implantation of synthetic mesh is associated with mesh-related complications. In addition, the exorbitant cost of synthetic mesh and lack of universal access limit the popularity of these procedures. The current study develops a unique technique known as laparoscopic non-mesh cerclage pectopexy (LNMCP), in which permanent cervical cerclage sutures are embedded in the round ligament until the iliopectineal ligament. The iliopectineal ligament was sutured, resulting in a firm cervical suspension. The procedure was successfully performed in 16 cases in the hospital. The surgical duration was 67.8 min &plusmn; 15.5 min, and the blood loss was 73.1 mL &plusmn; 51.1 mL. No procedural complications were seen. LNMCP is associated with an objective success rate of 100% and a subjective success rate of 93.8%. LNMCP for patients with apical prolapse obviates the need for a mesh, thereby avoiding complications associated with mesh erosion and reducing medical costs. In addition, it is easy to perform even in resource-poor areas without access to synthetic mesh.

The present pilot study describes the development of laparoscopic non-mesh cerclage pectopexy to treat pelvic organ prolapse. The procedure can be used to prevent any complications associated with the use of mesh.

Pelvic organ prolapse (POP) is widespread among the female population and significantly impairs the patient's quality of life. It is important to restore ...

Application of a New Mesh Fixation Method in Laparoscopic Incisional Hernia Repair

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing incisional hernias. The laparoscopic IPOM involves implanting the mesh into the abdominal cavity through laparoscopy to repair an abdominal wall hernia. In the IPOM surgery, after the closure of the hernia ring, an anti-adhesion mesh is placed laparoscopically. The correct placement of this mesh is critical to the success of the method, and surgical skills are required to achieve perfect placement. If the mesh placement is not mastered properly, the operation and anesthesia time will be prolonged. In addition, improper placement of the mesh can lead to serious consequences, such as intestinal obstruction and mesh infection. A "contraposition and alignment" mesh fixation method is described in this study, which involves pre-marking the fixation position of the mesh to reduce the difficulty of mesh placement. A properly placed mesh is completely flat on the peritoneum, the edges are not curled or wrapped, and the mesh is adhered firmly such that there is no displacement after removing the pneumoperitoneum pressure. The "contraposition and alignment" mesh fixation technique offers the advantages of reliable placement of the mesh and fewer complications than other techniques, and it is easy to learn and master. It also allows for positioning the nail gun in advance based on the anatomy of the incisional hernia. This enables the use of the minimum number of nails possible while still ensuring good fixation, which can reduce the occurrence of complications and reduce the cost of surgery. Thus, the mesh fixation method described here is highly suitable for clinical applications based on the aforementioned advantages.

Presented here is a method for improving the mesh placement in laparoscopic incisional hernia repair, which can shorten the time required for mesh fixation and reduce the occurrence of postoperative chronic pain.

Laparoscopic incisional hernia repair using intraperitoneal onlay mesh (IPOM) is one of the most widely used minimally invasive methods for repairing ...

Robotic Myotomy and Partial Fundoplication for Achalasia

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller myotomy has emerged as an alternative approach to traditional laparoscopy due to three-dimensional (3D) visualization, fine motor control, and improved ergonomics provided by the robot. 
Although there is a lack of randomized controlled trials, robotic-assisted Heller myotomy seems to be associated with lower rates of intraoperative perforations compared to the laparoscopic approach. A robotic approach may also improve surgical outcomes by providing a more complete myotomy. 
Here, we describe the detailed steps of robotic myotomy and partial fundoplication for achalasia.

Surgical myotomy with a partial fundoplication may be used in selected patients as a definitive treatment for achalasia. This article provides a step-by-step description of a robotic myotomy and partial fundoplication in a 32-year-old patient with megaesophagus.

Laparoscopic Heller myotomy is currently considered the standard definitive treatment of achalasia. With the advancements in technology, robotic Heller ...

Reoperative Hiatal Hernia Repair

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical ...

Novel PLL-AF Suture Technique for Annulus Fibrosus Repair in Lumbar Endoscopy

A Suture Technique for Ruptured Annulus Fibrosus Following Decompression Under Percutaneous Transforaminal Endoscopic Discectomy

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full decompression has been shown to decrease the recurrence rate of lumbar disc herniation during endoscopic surgery. Traditional suture operations under endoscopy involve only simple suturing of the ruptured AF. Due to the weak and poor quality of the AF tissue around the tear portal, using this area as needle insertion points during suturing may lead to insufficient tension and a low success rate of AF closure. Currently, there is no detailed technical illustration based on video for AF tear suturing under lumbar full-endoscopy. We innovatively propose a method of covering and suturing the AF tear by pulling up the posterior longitudinal ligament (PLL) under lumbar endoscopy and using three stitches (PLL-AF suture technique). The patient who received the novel suture technique achieved satisfactory results. Six months after the operation, lumbar MRI showed no evidence of recurrence in the outpatient clinic.

Author Spotlight: Development and Application of a Novel Suture Technique for Annular Fibrosus Repair in Percutaneous Transforaminal Endoscopic Discectomy

This protocol describes an innovative suture technique for ruptured annular fibrosus during percutaneous transforaminal endoscopic discectomy.

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full ...