Herniation of the Wrap into the Chest

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Herniation of the fundic wrap into the chest may occur in the early postoperative period, even as early as while the patient awakens from the anesthetic. Various conditions predispose to this unfortunate outcome:

• The physiologic intraabdominal pressure is higher than the one existing in the thorax so that abdominal organs are naturally attracted to the chest through any defect in the diaphragm, the roof of the abdominal cavity.

• A sudden increase in abdominal pressure, as may occur when the patient strains while awakening from anesthesia, may push the freshly constructed wrap through the hiatus, with subsequent breakdown of the crural closure.

• The absence of any crural closure gives even better access to the lower mediastinum, especially in patients operated on for gastroesophageal reflux disease with a hiatal hernia and in whom the fundic wrap has not been anchored to the hiatal sling.

• Postoperative distension, which may occur if a nasogastric tube has not been placed, may put the hiatal repair under stress and account, in part at least, for the acute disruption of the crural sutures.

• In the presence of esophageal shortening, undue traction on the esophageal tube to construct the wrap below the diaphragm also predisposes to early herniation into the chest, which reflects the spontaneous tendency of the short esophagus to go back to its natural location in the lower mediastinum.

• In those patients operated on for a short esophagus, inappropriate anchoring of an intrathoracic Nissen fundoplication45 to the crural sling predisposes to either further herniation of the stomach or herniation of the splenic flexure of the colon alongside the fundoplication into the chest.47

• After discharge home, manual workers should be advised against carrying heavy loads; similarly, patients with prostatism or constipation should be warned not to strain too much when they urinate or have a bowel movement. Each of these conditions increases intraabdominal pressure excessively and can predispose to breakdown of a repair and wrap herniation.

• Herniation of the fundoplication into the chest is more common with the laparo-scopic approach than after conventional surgery.10 Possible reasons for this are excessive cautery of the peritoneal sheet covering the crura and misestimation of the amount of tissue incorporated in bites when approximating the crura with the laparoscopic technique.52

Total disruption of the crural closure with herniation of the wrap into the chest may remain totally asymptomatic. Sometimes the fundoplication has sufficient room in the hiatus and has become fixed in the lower mediastinum, creating a situation similar to what is achieved when an intrathoracic fundoplication is constructed around a short esophagus.46 To be effective in controlling gastroesophageal reflux, a total fundoplication does not necessarily have to be located below the diaphragm; rather, our own experience of intrathoracic Nissen fundo-plications when performed for true esophageal shortening indicates that an intrathoracic wrap is at least as effective as an intraabdominal one, with a long-term pH-controlled success rate of 97%.48

Partial disruption of the crural closure, together with the absence of spontaneous fixation of the herniated wrap to the lower mediastinal tissue, may result in gastric compression at the diaphragmatic level. This can lead to dysphagia, chest pain, dyspnea, and cardiac dysrhythmia, symptoms that require reoperation to reposition the fundoplication below the diaphragm. Usually, herniation of the wrap into the chest is not the only anatomic abnormality found at reoperation.37,53 The wrap is often found to have been partially disrupted, sometimes the wrap no longer exists, or the


wrap may have slipped onto the gastric body. Patients with these anatomic problems experience recurrence of heartburn, which requires take down of the residual wrap followed by the construction of a proper one around the lower esophagus below the diaphragm.

Acute transhiatal herniation of the wrap through a relatively narrow hiatal sling may result in strangulation of the hernia with gastric necrosis (Figure 6.4). This life-threatening complication requires an emergency operation and may require resection of the fundus or even esophagogastrectomy whenever the gastric wall cannot be sutured after the removal of the necrotic area.

Techniques for preventing herniation of an intraabdominal fundoplication into the chest include the following:

• Proper approximation of the diaphragmatic crura with incorporation of their sturdy peritoneal sheet in the suture

• Anchoring of the wrap to both diaphragmatic crura with nonabsorbable sutures

• Smooth recovery from anesthesia, preventing the patient from excessive coughing

• Placement of a nasogastric tube during the first 12 hours after the operation

Slipped Nissen Fundoplication Symptoms
Figure 6.4. Acute herniation and diaphragmatic strangulation (black arrow) of the greater curvature after laparoscopic Nissen fundoplication in relation to postoperative vomiting.

• A 2-month convalescence period for manual workers

• Appropriate management of prostatism and constipation during the early postoperative period

• True esophageal shortening on preoperative barium swallow series must be operated on via thoracotomy45'46

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