Get Exposure Before You Start Pulling
Reduce stomach gently, divide short gastrics when needed, expose both crura, and identify the sac. Pulling on the esophagus before the sac is free is how you create a problem.
Surgical Case Prep Flagship
How to Prepare for Hiatal Hernia Repair
Type I-IV hiatal hernias, paraesophageal hernia strategy, mediastinal dissection, esophageal length, cruroplasty, mesh reinforcement, recurrence, volvulus, gastropexy, documentation, CPT, and wRVUs.
Overview
Type I-IV hiatal hernias, paraesophageal hernia strategy, mediastinal dissection, esophageal length, cruroplasty, mesh reinforcement, recurrence, volvulus, gastropexy, documentation, CPT, and wRVUs.
What Your Attending Expects You to Know Before Scrubbing In
- Type I sliding hernia
- Type II paraesophageal hernia
- Type III mixed hernia
- Type IV complex hernia
- short esophagus
- mediastinal dissection
Operative Atlas
Figure A: Where am I?
Figure B: How do I safely dissect?
Figure C: How do I decide if the esophagus is short?
Figure D: How do I repair it?
Figure E: When is a Nissen the right wrap?
Figure F: When is a Toupet safer?
Figure G: When does Dor solve a different problem?
Operative Videos
Real operative video integration is intentionally curated, not scraped. Until an approved public or Graydon-owned video is embedded, use the atlas above as the key-frame map and review any operative footage against these moments: sac reduction, circumferential mediastinal mobilization, length assessment, crural closure, selective mesh, gastropexy, and wrap geometry.
- Pause at first view of the hiatus and name both crura.
- Identify the plane between hernia sac and mediastinum.
- Watch how the pleura is protected or decompressed.
- Confirm where length is judged before any wrap is built.
- Ask whether the final repair is tension-free or cosmetic.
Operative Anatomy
Hiatal Landmarks
Right crus, left crus, anterior vagus, posterior vagus, phrenoesophageal membrane, left gastric pedicle, short gastrics, pleura, pericardium, aorta, and the GE junction.
Hernia Types
Type I is sliding GE junction migration. Type II is true paraesophageal herniation with GE junction in place. Type III combines both. Type IV brings stomach plus another viscus into the chest.
Mediastinal Plane
The safe plane is on the hernia sac, not in the esophageal wall. Circumferential mobilization should create a posterior window and restore at least 2.5-3 cm of tension-free intraabdominal esophagus.
Failure Anatomy
Recurrence usually reflects missed sac, inadequate length, crural tension, poor tissue, wrap migration, or failure to anchor the stomach when gastropexy was the better operation.
Indications
Symptomatic Paraesophageal Hernia
Postprandial pain, early satiety, regurgitation, dysphagia, dyspnea, aspiration, anemia from Cameron lesions, or impaired quality of life.
Acute Presentation
Gastric volvulus, obstruction, ischemia concern, bleeding, or inability to decompress. The first decision is source control and viability, not perfect elective reconstruction.
Reflux-Dominant Disease
GERD with objective reflux, anatomy suitable for repair, and a workup that supports an antireflux operation rather than isolated medical therapy.
Reoperative Failure
Recurrent hernia, slipped wrap, obstructing wrap, recurrent volvulus, or mesh/wrap complication after careful imaging, endoscopy, and physiology review.
Contraindications
Hard Stops
- No objective symptom, risk, or anatomic indication.
- Unresuscitated shock when laparoscopy will delay control.
- Non-survivable physiology outside a palliative goal.
- Patient cannot tolerate pneumoperitoneum or anesthesia.
Relative Contraindications
- Severe frailty favoring gastropexy over formal repair.
- Hostile reoperative mediastinum or prior mesh erosion.
- Severe dysmotility arguing against a full Nissen.
- Poor tissue quality making mesh or staged repair a judgment call.
Patient Selection
- Define the symptom driver: reflux, obstruction, anemia, aspiration, volvulus risk, dysphagia, or recurrent failure.
- Preop workup usually includes CT or esophagram for anatomy, EGD for mucosa and Cameron lesions, and manometry/pH testing when reflux physiology will determine wrap choice.
- In frail volvulus patients, gastropexy may be the right operation. In durable elective candidates, formal sac reduction, crural repair, and fundoplication are usually the goal.
Operative Strategy
Mobilize the Mediastinum Completely
Perform complete circumferential mediastinal mobilization, protect both vagus nerves, stay on sac, and develop enough length that the GE junction sits below the crura without traction.
Measure Length Honestly
If you cannot get 2.5-3 cm of tension-free intraabdominal esophagus after real mobilization, call it a short esophagus. A tight wrap on a short esophagus is a recurrence plan.
Close the Crura Without Strangling the Esophagus
Posterior cruroplasty is standard. Calibrate around the esophagus, assess tissue quality, and avoid making dysphagia the price of a pretty hiatus.
Choose the Antireflux Operation
Nissen requires acceptable motility and a short floppy wrap. Toupet is safer for weak motility or dysphagia risk. Dor is a different tool, often used when anterior coverage is the goal.
Add Mesh or Gastropexy for a Reason
Mesh is for selected large defects, poor crura, or recurrence risk. Gastropexy is for volvulus control, frailty, high-risk recurrence, or when a full repair is unsafe.
Common Pitfalls
Leaving sac behind and calling the stomach reduced.
Failing to recognize a true short esophagus.
Building a wrap under tension.
Injuring pleura and ignoring capnothorax physiology.
Overtight cruroplasty causing postoperative dysphagia.
Using mesh as a substitute for mobilization.
Bailout Strategies
Pleural Violation
Tell anesthesia, reduce insufflation pressure, watch ventilation and hemodynamics, decompress if tension develops, and place a drain/chest tube only when physiology or injury requires it.
Short Esophagus
Mobilize more before declaring failure. If length remains inadequate, consider Collis gastroplasty or referral/staging rather than forcing a high-tension repair.
Hostile Reoperative Hiatus
Identify prior wrap and mesh, use EGD liberally, preserve the vagus nerves if possible, and convert before esophageal injury becomes the operation.
Frail Volvulus Patient
Reduce, assess viability, decompress, and consider anterior gastropexy or PEG gastropexy when definitive reconstruction is more dangerous than recurrence.
Complication Management
Esophageal or Gastric Perforation
Recognize intraoperatively, repair in healthy tissue, test with EGD or air leak, drain, consider stent when appropriate, and do not hide the injury in the op note.
Postoperative Dysphagia
Separate edema from mechanical obstruction. Start with diet modification and imaging/endoscopy; dilate selectively and revise only when anatomy proves the repair is the problem.
Gas-Bloat or Delayed Emptying
Consider tight wrap, vagal injury, or unmasked gastroparesis. Manage diet and symptoms first, then define anatomy before contemplating revision.
Recurrence or Slipped Wrap
Work up mechanism with CT/esophagram/EGD. Recurrence from tension, missed short esophagus, or failed crura needs a different plan than simple recurrent reflux.
Mesh Erosion or Stricture
Rare but serious. Define location endoscopically, involve experienced foregut help early, and plan reoperation around esophageal preservation rather than mesh removal alone.
Splenic Bleeding
Usually from short gastric or fundus traction. Pack, expose, control the source, and convert if visualization is not good enough to make the next move safely.
Interactive Pimp Questions
Click any card to reveal the answer. Use filters for student, resident, and advanced decision-making review or Quiz Mode for one-question-at-a-time board prep.
Graydon's Pearls
Surgical Decision Challenges
Six realistic case stems that teach operative judgment, prioritization, bailout thinking, and documentation discipline.
These cases are educational examples for surgical learning and documentation awareness. They are not patient-specific medical advice. Actual management depends on patient physiology, anatomy, local resources, attending judgment, and institutional protocols.
CPT Coding Pearls
Values below are pulled from the FreeCPTCodeFinder CPT database at runtime so RVUs and estimated Medicare payments stay aligned with the coding engine.
- 43281 is the key laparoscopic paraesophageal hernia repair code when repair includes fundoplasty.
- 43332 and 43333 describe Collis gastroplasty work; document why lengthening was required.
- Use unlisted 43999 only when no existing CPT describes the work, and give a comparison code plus operative rationale.
- Mesh, gastropexy, EGD, difficult dissection, and reoperative scar may affect documentation and modifier judgment even when not separately payable.
Documentation Pearls
- Hernia type and objective indication.
- Approach, ports, reduction, and whether a complete sac dissection was performed.
- Vagus nerves identified and preserved, or why they could not be safely defined.
- Intraabdominal esophageal length after mediastinal mobilization.
- Crural closure technique, calibration, suture type/count, and mesh rationale if used.
- Wrap type, geometry, length, orientation, and why that wrap fit the manometry/clinical context.
- Gastropexy method and intent if performed.
- Complications, pleural entry management, EGD/leak test, drains, diet plan, and bailout decisions.