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Morgan Randall

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Paraesophageal Hernia

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Indications Patients with a PEH will present with: Gastroesophageal Reflux Disease (GERD) Dysphagia Epigastric Pain Vomiting Barretts Epithelium Postprandial Fullness or Pain Pulmonary Dysfunction

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Preoperative Tests Chest X-Ray Barium Esophagram Esophagogastroduodenoscopy Esophageal pH Study CT Scan (rare) MRI (rare) Pulmonary Function Test (rare)

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Classification Type I not considered a true PEH Upward migration of the GE junction into the mediastinum Hernia sac consists of visceral peritoneum, paraesophageal membrane, anterior wall of gastric cardia Type II Upward dislocation of fundus of stomach alongside a normally positioned intraabdominal GE junction

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Classification cont. Type III Upward displacement of both GE junction and gastric fundus More common than Type II Type IV aka Giant Contains viscera other than stomach

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Laproscopic vs Open Advantages of Laproscopic Procedure Quicker Recovery Decreased Length of Hospital Stay Quicker Return to Normal Activities Reduced Recurrence Rate Fewer Infections Smaller Incisions Advantages of Open Increased Abdominal Access

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Contraindications Contraindications for the laparoscopic approach Absolute contraindications: abdominal or mediastinal perforation. Relative contraindications single or multiple recurrences in patients with multiple abdominal scars (the thoracic route may be indicated in these patients),

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Instruments Used Scalpel Syringe 5mm, 10mm, 12mm Trocars 30 Laproscope Liver Retractor Harmonic Scalpel Atraumatic Graspers Articulating Grasper Penrose Drain 56 French Bougie Suction/Irrigation System Endo Universal 65 Stapler Bioilogic Implant Mesh Suture 0 Braided Silk 2-0 Braided Silk

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Room Setup

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Port Placement

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10mm Port 5mm Port 12mm Port 5mm Port 15 cm

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Room Setup

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Place Liver Retractor

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Important Structures http://upload.wikimedia.org/wikipedia/commons/4/4b/Gray793.png http://www.biology-online.org/articles/computer_simulation_analysis_normal/figures.html http://www.med.umich.edu/anatomy/plastinate/galleries/Green_Lab/Abdominal_Cross_Section.html

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Hernia Dissection

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Mobilize Fundus of Stomach

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Place Penrose Drain

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Hernia

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Stitch Hernia Closed

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Add Mesh and Staple in Place

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Nissen Fundoplication

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Endoscopy to Check Alignment

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Questions?

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Thank You

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Refrences Special Thanks to Dr. John Roth Benign Esophageal Disease. Thoracic Surgery. Stanford School of Medicine. http://thoracicsurgery.stanford.edu/patient_care/benign_esophageal.html Pierre, Andrew F. and Luketich, James D. Laproscopic Repair of Giant Paraesophageal Hernias. Cardiothoracic Surgery Network. http://www.ctsnet.org/sections/clinicalresources/thoracic/expert_tech-9.html Paraesophagel Hernia. Mount Sinai School of Medicine. http://www.mssurg.net/Team5Conferences/Paraesophageal%20Hernia%20- 2.pdf Laparoscopic Paraesophageal Hernia. Ohio State University Center for Minimally Invasive Surgery. The Ohio State University. Department of Surgery. http://cmis.osu.edu/8818.cfm www.websurg.com UK HealthCare. Hernia Facts Sheet. http://www.ukhealthcare.uky.edu/publications/healthfocus/fact_sheets/herni as.asp

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Endo Universal 65 http://www.covidien.com/hernia/us/fixation/endouniversal RETURN

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30 Endoscope http://www.stryker.com/en-us/products/Endoscopy/Laparoscopy/Laparoscopes/StandardLengthLaparoscopes/index.htm RETURN

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Trocar Available in 5mm, 8mm, 10mm, 12mm http://www.ethiconendosurgery.com/Clinician/Product/access/trocars/xcelbladeless#About RETURN

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Biologic Implant Mesh http://www.covidien.com/hernia/us/biologics/permacol RETURN

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Maryland Dissector http://www.ethiconendosurgery.com/Clinician/Product/endodevices/endohandinstruments#description-specs RETURN

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Penrose Drain http://www.covidien.com/criticalcare/pageBuilder.aspx?webPageID=0&topicID=67861&xsl=xsl/productPagePrint.xsl RETURN

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56 French Bougie http://www.stryker.com/en-us/products/Endoscopy/Laparoscopy/AccessoriesandDisposables/InfraVisionEsophagealKit/index.htm RETURN

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Articulating Grasper http://www.covidien.com/autosuture/pagebuilder.aspx?topicID=195028&breadcrumbs=0:63659,172308:0,195057:0 RETURN

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Suction/Irrigation System http://www.endotek.com.tr/default.asp?L=EN&mid=173&cat_id=216 RETURN

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Scalpel http://www.google.com/search?hl=en&sugexp=ldymls&xhr=t&q=scalpel&cp=6&bav=on.2,or.r_gc.r_pw.&wrapid=tljp1303234486536010&um=1&ie =UTF-8&tbm=isch&source=og&sa=N&tab=wi&biw=1259&bih=617 RETURN

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Harmonic Scalpel http://www.ethiconendosurgery.com/Clinician/Product/energy http://www.hhsurgical.com/Products/Product/Electrosurgical-Units/NoSub/1445-Ethicon-G110-Harmonic-Scalpel-.chtml RETURN

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Syringe http://www.mediray.com/Pages/Products/SyringeShields.html RETURN

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Liver Retractor http://www.bristolsurgery.com/article.aspx?articleid=100749 RETURN

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Suture http://www.syneture.com/syneture/pageBuilder.aspx?topicID=315 http://www.sosmedicalsuperstore.com/PhotoGallery.asp?ProductCode=A306H RETURN