The fibrous connective tissue of the lower esophagus and the peritoneum are folded back to form the diaphragmatic esophageal ligament, and the esophageal foramen is surrounded by the muscle fibers of the diaphragmatic foot and crossed posteriorly, both of which play a relatively fixed role for the lower esophagus and the cardia in a normal state. As a result of dysplasia or long-term increase in abdominal pressure, the esophageal hiatus is enlarged and the diaphragmatic esophageal ligament is subsequently extended and relaxed, so that the cardia and upper part of the stomach can slide into the mediastinum through the enlarged esophageal hiatus in the horizontal position, forming a sliding esophageal hiatus hernia.
If the esophageal hiatus is enlarged, a blind sac is formed in front of the stomach and on the right or left side of the peritoneum, which protrudes into the thoracic cavity, and the anterior part of the stomach passes through the hernia sac so formed and herniates into the thoracic cavity on the anterior side of the lower esophagus, forming a paraesophageal hiatus hernia. Both types of esophageal hiatal hernia pass through the esophageal hiatus and the stomach partially herniates into the thoracic cavity, rather than passing through the diaphragmatic defect.
In the sliding type of hiatal hernia, the peritoneum is carried upward by the upwardly displaced cardia and fundus, failing to form an intact hernia sac. In the paraoesophageal hiatal hernia, there is a complete hernia sac and only the body of the stomach (mainly the antrum) herniates into the thoracic cavity, while the cardia remains in its normal position. Sliding hernias are more common in esophageal hiatal hernias, accounting for more than 90% of cases, while paraoesophageal hiatal hernias are less common.
[Indications]
The incidence of esophageal hiatal hernia is high, mostly in middle-aged and elderly patients, but not always with symptoms. If the symptoms are mild, medication can be used to relieve the symptoms, but only those who have obvious symptoms and cannot be treated with medication are suitable for surgery.
1, due to acid reflux, stimulation and corrosion of the lower esophagus, causing esophagitis, resulting in burning pain or discomfort in the epigastrium, heart fossa, bloating, acid reflux, belching, etc. gradually aggravated.
2. Inflammation and ulceration of the mucosa of the lower esophagus, producing vomiting of blood, tarry stools and anemia.
3.Esophageal scar stenosis formed by esophagitis over the years, resulting in swallowing difficulties.
[Preoperative preparation]
1.Correct dehydration and electrolyte imbalance.
2.Correct anemia and low plasma protein. Preoperative hemoglobin of not less than 10g/l is appropriate.
3.For severe acid reflux, belching and retrosternal burning pain, apply acid-control drugs before surgery to reduce the symptoms.
4. For those with constipation, laxative drugs should be given.
[Anesthesia]
Endotracheal intubation, controlled breathing, intravenous or inhalation anesthesia.
[Surgical steps]
1, Position, incision Right lateral position, left posterior lateral incision (see pleural fibrous plate stripping), enter the chest through the 7th or 8th intercostal space.
2.Expose the lower end of the esophagus Cut the left lower pulmonary ligament, cut the mediastinal pleura longitudinally, separate the lower end of the esophagus and wrap a gauze band around it, and carefully explore the herniation into the cardia of the stomach and the size of the esophageal fissure.
3.Return the peritoneum and diaphragmatic esophageal ligament around the esophagus, leaving its residual edge about 2 cm around the cardia, and return the cardia and gastric body into the abdominal cavity. At the posterior edge of the esophagus, add a stitch on the foot of the right diaphragm to set a marker for later suturing of the fissure.
4. Fixation The remnants of the peritoneal ligament left in the cardia are fixed around the diaphragmatic esophageal fissure with mattress silk sutures.
5., Reconstruction of the esophageal fissure After fixing the mattress suture ligation, sutures are placed posterior to the lower end of the esophagus to constrict the diaphragmatic foot, usually 2 to 3 stitches are sufficient.
6. Close the chest Suture the incised mediastinal pleura, place closed drainage of the chest cavity, and close the chest layer by layer.
[Intraoperative precautions]
1.When cutting the diaphragmatic esophageal ligament, take care not to injure the herniated gastric body, and repair carefully if there is any injury.
2. When reconstructing the esophageal fissure, suture reduction of the diaphragmatic foot should be appropriate so that the newly constructed fissure can accommodate the size of one finger, too large may easily recur, too small may cause esophageal obstruction.
3. The thoracic aorta is in the left front of the lower end of the esophagus. When separating the esophagus and suturing the diaphragm foot, be careful not to damage the thoracic aorta to avoid causing hemorrhage.
[Postoperative management]
1, Prevent pulmonary complications.
2. The gastric decompression tube should be placed for about 24 hours, and removed and fed after anal venting.
3. Give laxatives to those who are constipated and develop the habit of regular bowel movements to avoid constipation causing increased abdominal pressure and recurrence of postoperative hernia.
4. If there is still acid reflux, belching and retrosternal burning pain in the early postoperative period, continue to take acid-control drugs until the symptoms disappear.
5. Give antibiotics.