Laparoscopic PEH repair is performed under general anesthesia with endotracheal intubation and full paralysis. Patients are positioned supine with legs abducted. We tuck the right arm and abduct the left arm and use a vacuum beanbag mattress to support the patient’s sides and perineum. This positioning provides stability when the table is shifted into a steep reverse Trendelenburg position and helps to prevent neuropathy during what may be a lengthy operation. Pneumatic compression stockings and a urinary catheter are placed, and patients receive appropriate antibiotic prophylaxis prior to the initial incision.

Five trocars are utilized: one for the laparoscope, two for the operating surgeon, one for the assistant, and one for a liver retractor (Fig. 13.1). We begin by placing a 10-mm trocar slightly to the left of midline and superior to the umbilicus, approximately 12–15 cm from the xiphoid process. This is typically done using a Veress technique in patients without prior upper abdominal surgery, but an open Hasson technique may be used as well. Once this trocar is inserted and the abdomen insufflated, a 30- or 45° laparoscope is inserted and an initial diagnostic laparoscopy is performed. Use of an angled laparoscope during PEH repair is essential so that unobstructed views can be obtained when working in the confined space of the hiatus and mediastinum.

A 5-mm trocar for the liver retractor is then placed just below the right costal margin, approximately 15 cm from the xiphoid. We use a self-retaining retractor to elevate the left lateral segment of the liver and expose the hiatus. A 5-mm port for the assistant’s instrument is then placed in the right upper abdomen, approximately midway between the liver retractor and laparoscope ports. A common alternative is to place the assistant’s trocar in a lateral position below the left costal margin [18].

The two trocars for the operating surgeon’s instruments are then placed. The positioning of these ports is intended to create a triangulation effect, in which the two instruments enter the operative field at a 30–60° angle from either side of the laparoscopic image. The esophagus enters the abdomen through the hiatus at a right-to-left angle, so the surgeon’s two working trocars are also arranged “off center” towards the patient’s left side. For the surgeon’s right hand, a 10-mm trocar (to accommodate a curved needle) is inserted just inferior to the left costal margin, approximately 10 cm from the xiphoid process. We lastly place the surgeon’s left hand 5-mm trocar, slightly inferior and to the right of the xiphoid process. Depending on the size and anatomy of the liver, this trocar may need to be placed more inferiorly on the abdominal wall. For this reason, once the liver retractor has been secured, we test potential locations for this trocar by first passing a Veress needle through the abdominal wall to ensure that the working instrument will have a clear path to the hiatus.

Once the trocars have been placed, the patient is tilted to a steep reverse Trendelenburg position in order to shift the abdominal contents inferiorly, away from the hiatus, and to bring the patient’s upper abdomen closer to the surgeon, thereby improving ergonomics. This should be done slowly, and in coordination with the anesthesiologist, as this maneuver can significantly reduce venous return. The operating surgeon then moves to a position between the patient’s legs with the laparoscopic monitor placed directly over the head of the patient. The assistant stands to the patient’s right and the camera operator is seated in a stool to the patient’s left.

A thorough diagnostic laparoscopy is then performed, focusing on delineating the hernia anatomy. This can be difficult on initial inspection, as a significant portion of the stomach may be lying in the mediastinum. Of importance to note at the onset of the operation are the positions of the pylorus, left gastric artery, spleen, and short gastric vessels, as well as the width of the crural defect.

After initial anatomic identification, an attempt is made to reduce the stomach from the hernia sac and into the abdominal cavity (Fig. 13.2). This helps to facilitate the remainder of the operation by creating additional working space in the mediastinum. A hand-over-hand technique is used to gently pull the stomach inferiorly using atraumatic graspers. However, excessive force should never be applied to the stomach during this initial maneuver. Significant adhesions can exist between the stomach and the hernia sac, and traction under these conditions can result in gastric injury and even perforation. If the stomach does not reduce easily, this step should be abandoned and the operation proceeds with dissection of the hernia sac.

To initiate this dissection, the hepatogastric ligament is divided in order to gain access to the lesser sac and mobilize the lesser curvature of the stomach. In the case of a large type III PEH, a significant portion of the lesser curvature may lie intrathoracically. In operations involving this severe an anatomic distortion, the surgeon must be extremely careful to identify the location of the left gastric artery, right gastric artery, and even porta hepatis, prior to dividing the hepatogastric ligament, as these structures can be shifted towards the hiatus. The hepatic branch of the vagus nerve, on the other hand, can be divided without physiologic consequence.

Once the lesser sac is entered, division of the lesser omentum continues superiorly to the level of the right crus. We use an ultrasonic dissector to accomplish this, although bipolar or monopolar energy devices can also be employed. The next step is to enter the mediastinum and develop a plane on the outside of the hernia sac. The importance of this maneuver cannot be overemphasized, and the relative ease or difficulty of the remainder of the operation often hinges upon it. To achieve this, the surgeon grasps the right crus with a blunt grasper and then incises the peritoneal layer at its medial aspect (Fig. 13.3). The hernia sac is an extension of this peritoneal membrane and therefore if it is divided at the medial edge of the right crus, the mediastinum can be entered external to the sac. Once this entry is made, blunt dissection is used to sweep the sac and its contents medially and inferiorly, separating them from the rest of the mediastinal structures. The assistant forcibly retracts the hernia sac inferiorly in order to continuously reduce the hernia contents as the dissection proceeds. It should be noted that neither the surgeon nor assistant should grasp the esophagus directly, as it can be injured easily. During this portion of the procedure, the use of cautery should also be limited so as to not inadvertently cause a tear in the hernia sac or thermal injury to the esophagus or vagus nerves.

If the correct plane has been entered, the hernia sac should separate relatively easily, revealing the right-sided mediastinal pleura laterally, pericardium anteriorly, and vertebrae and aorta posteriorly. The anterior and posterior vagus nerves should be identified as well and kept alongside the esophagus. As this mediastinal working space is enlarged, the edge of the hernia sac is sequentially divided at its junction with the crura. This is done in a clockwise direction, starting at the point of mediastinal entry and proceeding towards the left crus. Blunt dissection of the hernia sac then proceeds to the patient’s left, and the left pleura is exposed. During this step in the operation, tears in the pleura on either side can occur. This usually does not result in adverse physiologic consequences, but the anesthesiologist should be immediately informed. In the case of capnothorax that results in hypotension or increased airway pressures, a reduction in insufflation pressure, or complete deinsufflation of the abdomen, will almost always correct these abnormalities. Insertion of a chest tube is rarely, if ever, required.