HOW I DO IT

Use of the Falciform Ligament Flap for Closure of the EsophagealHiatus in Giant Paraesophageal Hernia

Adrian E. Park & C. Marius Hoogerboord & Erica Sutton

Received: 9 February 2012 /Accepted: 3 April 2012 /Published online: 1 May 2012# 2012 The Society for Surgery of the Alimentary Tract

AbstractObjectives Laparoscopic repair of a giant paraesophageal hiatal hernia remains a challenging procedure. Several techniqueshave been developed in efforts to achieve tension-free reconstruction of the esophageal hiatus. In this report, we describe atechnique whereby the falciform ligament is used as an autologous onlay flap to achieve tension-free closure of the cruraldefect of a giant paraesophageal hernia (GPEH).Discussion Use of the falciform ligament as a vascularized autologous onlay flap is a safe and effective procedure to obtainclosure of the crural defect of a GPEH. The falciform ligament should be adequately mobilized from the anterior abdominalwall to prevent lateral tension on the flap, but care must be taken to avoid devascularization. Interrupted vertical mattresssutures are used to fix the falciform ligament to the left and right hiatal crurae.

Keywords Falciform ligament flap . Esophageal hiatus .

Paraesophageal hernia . Education . Laparoscopic .

Vascularized autologous onlay flap . Posterior hiatoplasty .

Mesh . Biological mesh

Introduction

One of the most complex decisions in laparoscopic giantparaesophageal hernia (GPEH) repair revolves around theoptimal method of closing the crural defect. Reconstructionof the esophageal hiatus by reapproximation of the left andright hiatal crurae with interrupted sutures (posterior hiato-plasty) often results in significant tension on the repair.Failure of the posterior hiatoplasty is known to be the mostcommon cause for hernia recurrence.1,2 Several surgicaltechniques have been suggested to decrease the rate ofrecurrence, including efforts at creating a tension-free repairby the use of synthetic and biological mesh.3–5 Use of thefalciform ligament as a vascularized autologous flap fortension-free repair of a large hiatal defect is an attractiveoption for obtaining tension-free repair of a GPEH withoutthe risks associated with prosthetic materials or the substan-tial cost of biologic mesh. This paper describes our tech-nique for GPEH repair in 15 patients using the “falciformflap” as an autologous onlay flap to achieve tension-freeclosure of the crural defect of a large paraesophageal hiatalhernia.

A. E. Park (*)Anne Arundel Medical Center,2001 Medical Parkway,Annapolis, MD 21401, USAe-mail: apark@aahs.org

C. M. HoogerboordDalhousie University,Room 818, Victoria Bldg.,1276 South Park Street,Halifax, NS B3H 2Y9, Canadae-mail: Hoogerboord@gmail.com

E. SuttonDepartment of Surgery,University of Louisville School of Medicine,2nd Floor ACB, 550 S. Jackson St.,Louisville, KY 40202, USA

J Gastrointest Surg (2012) 16:1417–1421DOI 10.1007/s11605-012-1888-4

Operative Technique

Patients who are candidates for GPEH repair undergo acomplete preoperative workup for both the surgical pathol-ogy and any medical comorbidities relevant to undergoing ageneral anesthetic and hiatus hernia repair. In addition to acomplete history and physical examination, a minimal hiatalhernia preoperative workup includes an esophagogastroduo-denoscopy, a CT scan of the chest and upper abdomen,esophageal motility studies and baseline bloodwork.Patients receive detailed instructions regarding a graduated8-week postoperative diet plan that starts off with clearfluids and gradually reintroduces solids.

Patient Positioning and Port Placement

The patient is placed in the low lithotomy position. Asuction bean bag positioner is not required or routinely used.Both arms are tucked at the sides. The operating surgeonstands between the patient’s legs with the first and secondassistants on the patient’s left and right, respectively. Pneumo-peritoneum is established via insertion of a Veress needle.A 5mm 30 ° laparoscopic telescope is then introduced underdirect visualization via a direct view port, approximatelyone third to one half of the distance between the umbilicusand xiphoid process. All further ports are placed underdirect visualization. A 5mm port is placed at the xiphoidprocess to facilitate retraction of the left lobe of theliver, 5mm working ports are placed in the left and righthypochondriae, and a 5mm assistant’s port is placed in theleft flank just inferior to the left costal margin (see Fig. 1).

Surgical Procedure

The patient is then placed in reverse Trendelenburgh posi-tion. By using gentle traction, the hernia contents are re-duced. The gastrosplenic ligament and short gastric vesselsare routinely divided with the use of an ultrasonic dissector,

and the gastric fundus is completely mobilized. Becausegastric volvulus is often associated with these hernias, itmay obscure normal anatomy. Therefore, it is very impor-tant at this point to maintain correct orientation of thestomach to avoid veering into the lesser omentum withsubsequent unintended devascularization of the lessercurvature.

The dissection is carried to the base of the left crus whereattachment of the hernia sac is most consistent. Dissectionof the sac is then carried into the posterior mediastinum. Thedistorted gastric anatomy can make identification of theesophagus difficult. Great care must therefore be taken notto cause an iatrogenic esophageal injury at this point. This isachieved by staying close to the lateral aspect of the herniaand to free the sac with blunt dissection and minimal use ofthe harmonic scalpel until the esophagus is identified. Aftermobilization of the anterior and left sides of the esophagus,attention is turned to the lesser omentum. The pars flaccidais divided, and the base of the right crus is identified.Dissection of the hernia sac is again started at this positionand carried into the mediastinum with mobilization of theright side of the esophagus. Posterior mobilization of the sacand esophagus is completed next. It is critical to completelymobilize the esophagus as high up in the mediastinum as issafely possible in order to prevent tension on and eventualintrathoracic displacement of the fundoplication.

A Penrose drain is passed around the esophagus and isused for gentle retraction so as to expose the base of theesophageal hiatus. A clinical assessment is then performed,and if the size of the defect and rigidity or frailty of the cruraprohibits a suture approximation of the crurae, a falciformflap is developed and used as an onlay mesh to achieve atension-free closure of the defect. Even in such cases, anattempt is made to reapproximate the crura by one or twostitches of 2-0 silk, anterior to the aorta. The falciformligament is mobilized at the level of its attachment to theanterior abdominal wall starting just superior to the umbili-cus and continuing superiorly and anterior of the liver. Thisis done with ultrasonic dissection through the left flank portand retracted with an atraumatic grasper via the port in theleft hypochondrium (see Fig. 2).

A 54-Fr bougie is introduced transorally and advancedinto the stomach under laparoscopic visualization. The fal-ciform flap is then guided under the lateral segment of theleft lobe of the liver and maneuvered posterior to the esoph-agus to cover the hiatal defect (see Fig. 3). Its orientation ischecked to exclude torsion. Beginning with the right crus,the flap is secured to the crurae with several interruptedvertical mattress sutures of 2-0 silk. A minimum of twosutures are placed through each crus, and a stitch is alsoplaced inferiorly, in the midline at the level of the mostinferior crural reapproximation. When possible, one or twosutures are also placed lateral to the left crural stitches (see

Fig. 1 Trocar placement. Left upper quadrant site is for a 10mm trocar,and all others are for 5 mm

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Fig. 4). The bougie is used as a guide to prevent excessivenarrowing of the hiatus and impingement of the flap on theposterior wall of the esophagus. Finally, a 360° Nissen fundo-plication is performed to complete the procedure (Fig. 5).

Postoperative Care

Following surgery, patients are admitted to the hospital.They are started on sips of water after correct positionof the wrap is confirmed and iatrogenic distal esopha-geal obstruction is excluded by a contrast swallow studyon day 1 post-op. Early mobilization is encouraged, andall patients are prescribed incentive spirometry to facilitatelung reexpansion.

Patients are typically discharged on day 1 post-op afterdysphagia has been clinically excluded. Diet is slowly

advanced, and solids are reintroduced over a period of8 weeks. All patients are followed up at 4 to 6 weeks inclinic. At the 4-week follow-up clinic visit, patients areassessed for dysphagia symptoms and weight maintenancevia history and physical examination. Diet compliance isreviewed for appropriate food choices, smaller portions takenmore frequently and allowing more time to consume meals(20–25 min).

Anecdotally, it can be reported that this technique has beenused on 15 patients, over the past 4 years, when it was notpossible to achieve adequate hiatal closure by reapproximationof the crura. Although radiologic assessment has not beenemployed in the routine follow-up of these patients, there havebeen neither clinical recurrences nor the need for furtherGPEH-related interventions, to date. In two patients, a subse-quent unrelated laparoscopic procedure was required, and ineach case, the falciform flap repair was observed to be intact.

Fig. 2 Using an ultrasonic dissector, the flap is elevated at the level ofthe anterior abdominal wall, starting above the umbilicus and progress-ing toward the diaphragm

Fig. 3 The falciform flap is drawn under the lateral segment of the leftlobe of the liver

Fig. 4 The falciform flap secured in place, reinforcing the crural repairand/or covering the hiatal defect

Fig. 5 Intraoperative view of the completed falciform flap repair usedto bridge a large hiatal defect. A Undersurface of the liver (retractedcephalad), B completed falciform flap covering the partially closedhiatus, C esophagus encircled in Penrose drain (retracted laterally), Dgastric cardia

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Discussion

For historical context, it is helpful to recall that hiatus hernia(HH) was first reported by Bowditch6 in 1853, and cruralrepair was first performed by Soresi7 56 years later, in 1919.It was not until the 1950s that Allison8 and Barrett9 notedthe association between hiatus hernia and gastroesophagealreflux. Nissen10 described his fundoplication in 1956. Para-esophageal hernias represent 5–10 % of all hiatal hernias.11

Although definition of a giant paraesophageal hernia is notuniform, it usually implies at least 30 % of the stomachherniating into the posterior mediastinum. Due to the ab-sence of consensus on the definition of the condition, theincidence of GPEH is difficult to accurately determine.12

Principles of paraesophageal hiatus hernia repair includereduction of the hernia, complete excision of the sac, adequatecrural closure, maintenance of a subdiaphragmatic esophagus,and an antireflux procedure.13,14 An essential step of the oper-ation is reconstruction of the esophageal hiatus by reapprox-imation of the hiatal crurae posterior to the esophagus(posterior hiatoplasty). In the case of a GPEH, this often resultsin significant tension, contravening one of the most importantprinciples of hernia surgery. As well, the crural muscle fibersare without tendinous reinforcement and provide weak anchor-ing for sutures. The dynamic nature of the esophageal hiatuswith constant movement of the diaphragm, esophagus,stomach, and pericardium as well as the pressure gradientfrom thorax to abdomen, which is accentuated by Valsalvamaneuvers (e.g., laughing, sneezing, etc.), are all contributingfactors to failure of the hiatal repair.5

The radiological recurrence rate, following laparoscopic su-ture repair of a GPEH, has been reported as high as 42%.15 It isunderstood that radiologic evidence of failure of a HH repairdoes not necessarily correlate with clinical evidence of failure.Consequently, patients who have undergone repair of GPEHcan be found to have anatomic evidence (to varying degrees)of hernia recurrence without clinical evidence or return ofsymptoms.16 In fact, only a minority of those patients withanatomic recurrence actually manifest clinical failure of therepair.16,17 The reasons for this are poorly understood. Break-down of the posterior hiatoplasty is the most common cause ofa recurrent hiatal hernia and failed antireflux surgery.11

Several techniques have been employed in efforts toaccomplish a tension-free repair of the esophageal hiatus.These include the use of several different synthetic nonab-sorbable meshes and biologic meshes. Although an exhaus-tive review of mesh options for hiatal hernia repair isbeyond the scope of this article, a brief summary may behelpful. Of the many ways to categorize hernia meshes,when considering implantation in and around the esophage-al hiatus, only two types of mesh have been used. Histori-cally, a synthetic nonabsorbable mesh, even with anadhesion barrier, has significantly reduced HH recurrence

rates,16,18 while resulting in appreciably greater esophago-gastric morbidity, compared to the standard suture repair.19

The anecdotally reported occurrences of transesophageal orgastric erosion of such meshes are too numerous to ignore.Considering further accounts of mesh-related esophagealstrictures and odynophagia, conventional wisdom woulddictate that despite the benefits of improved long-term repairdurability, synthetic nonabsorbable meshes should no longerbe placed in proximity to the distal esophagus.19,20

Biological mesh is the other category of mesh being usedto reinforce hiatal repairs. These meshes are based on someform of collagenous matrix derived from human or porcinedermis, bovine pericardium, or porcine intestinal submuco-sa. Theoretically, once implanted, they are eventuallyreplaced by host collagen and blood vessels. While showinggreat promise in a few select applications, their role insupporting long-term durable hiatal repairs is far fromestablished.21 Early encouraging results from a randomizedprospective study comparing biologic mesh (vs. none) rein-forcement of a sutured hiatal repair were negated by longer-term follow-up by the same investigators.5,21 Furthermore,biologic meshes tend to be thick, variably rigid, and opaque,rendering correct positioning and fixation at the diaphrag-matic hiatus difficult. These meshes are significantly moreexpensive than all other categories of mesh and so their usemust be well supported by evidence of benefit and costeffectiveness, which is currently lacking.

Complications associated with the use of synthetic meshin the repair of a GPEH can be prevented by the use of thefalciform ligament as an onlay flap. This results in tension-free or buttressed repair with essentially an autologous well-vascularized pedicle flap, the ideal “biologic” material.

The concept of ligamentum teres reinforcement of ahiatal closure has been previously reported by Varga et al.5

In their series of 26 patients, following successful posteriorhiatoplasty performed both laparoscopically and open, theligamentum teres was used to reinforce the hiatal closure.Their results demonstrated the technique to carry low mor-bidity (11 %) and mortality (0 %) with a radiologic recur-rence of 15 % at a mean of 3 years follow-up.22

The technique we describe is different in that a flap israised along the length of the mobilized falciform ligament.This results in a vascularized flap of tissue that can be usedto both reinforce a completed hiatoplasty and, more unique-ly, bridge a defect when the crura cannot be reapproximated.This provides a barrier to egress of bowel or other abdom-inal contents into the mediastinum and was, in fact, theimpetus for developing the technique when no other meansof hiatal closure was available. Biologic meshes cannot beused to span a defect, and nonabsorbable meshes should notbe used to span a hiatal defect.

The purpose of this article is to describe this noveltechnique of laparoscopic falciform flap repair of GPEH

1420 J Gastrointest Surg (2012) 16:1417–1421

rather than to report upon a prospective series in detail. Dataon the long-term efficacy of the technique are limited.

Although there is some variation in anatomy, the bloodsupply to the falciform ligament comes mainly frombranches of the left hepatic and left inferior phrenic arterieswhich anastomose to form an arcade as well as from smallerperforators from the parietal peritoneum.4 It is important tomaintain the integrity of the arterial arcade during mobili-zation of the ligament and this is best ensured by keepingthe line of dissection as close to its attachment to the anteriorabdominal wall as possible. Placing the interrupted horizon-tal mattress sutures can be quite challenging especially at thebase of the right crus and must be undertaken with greatcare. The vena cava is usually in close proximity.

The falciform flap technique of repairing a GPEH allowsthe foregut surgeon the option to bridge an otherwise“unclosable” hiatal defect with patient’s own tissue, thusavoiding the risks, complications, and costs inherent in theuse of currently available meshes.

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