I was doing same that is anchoring the wrap to the crus earlier but most of the patients used to complain of discomfort while swallowing .I could not confirm this by any test,hence discontinued and gone back to standard procedure.

Many thanks

I also doing the same for 10 years , posterior wrap of fundus after good mobilization of the Esophagus down and aprroximation of Crura

Then post Wrap 270 degree and fixation of first suture to the right crura

Great to hear

Thank you for your question.

We also anchor the fundus wrap to contain migration.

Please refer to our publication- Prof G. Falk & Dr T. D'Netto-

A Technique for the Laparoscopic Repair of Paraoesophageal Hernia Without Mesh, November 2013, Journal of Gastrointestinal Surgery 18(4)

DOI: 10.1007/s11605-013-2397-9

Source Pubmed

We have described our technique and the rationale in the article

.

Comments in the publication of relevance are-

1. " Two sutures incorporating generous ‘bites’ of the oesophagus and cardio-oesophageal junction, posterior fundus, median arcuate ligament and repaired crus were placed using 2/0 Ethibond (Fig. 6) "

2. " this procedure describes the technique in the last 154 cases since March 2009. There has been substantial improvement in the quality of life and little new dysphagia. "

Hope this perspective informs the discussion.

Cheers, thanks for the publication link. bw

We use ant.wall of funds to wrap till .now no problem

Great to know. Thanks

I have always secured the wrap to the crura but by itself this does not prevent migration of the wrap into the chest. . The cause of migration of the wrap is inadequate mobilization of the intra-thoracic esophagus through the hiatus and resulting upward tension on the wrap. Since we have transitioned to robotic repair of large mixed paraesophageal hiatal hernias I have been impressed with how much higher up in the chest we are able to mobilize the esophagus. This allows a longer segment of intra-abdominal esophagus to be available and and resulting lack of tension on the wrap. In addition we use horizontal pledged sutures to re-approximate the crura which I believe is more secure than simple sutures.

I agree

Thank Christina and Pradeep,

Agree, I too use Pledgets (call it pledget hiatoplasty!) selectively in those cases. In some patients reinforce with a biological mesh.

Anchoring the wrap, in an uncomplicated patients without a large hiatal defect, is more or less routine, not seen any major comorbidity without any significant proximal migration down the line. Many thanks for sharing

Thanks for the interesting debate you started here Dr. Viswanath.

I agree with Dr. Williamson. In all cases, I mobilize the oesophagus up to the level of the inferior pulmonary veins to get at least 4 cm available. During the (2 stitch) wrap, I take one stitch to include oesophageal wall. After the wrap, 1-2 stitches are taken on the right crus to minimize migration risk.

Dr. Mahawar - What is your opinion on the fact that posterior 'floppy' wraps are known to be superior to other wraps in reflux control? Regarding the short gastric vessels division issue, I follow the SAGES guidelines, which says

"When the fundus can be wrapped around the esophagus without significant tension, no division of the short gastrics seems necessary (Grade A). Division should be undertaken when a tension-free fundoplication cannot be accomplished (Grade B). It should also be noted that expert opinion in North America advocates for the routine division of the short gastric vessels to minimize tension (grade C)"

We anchor the stomach to the crura- 'cardiopexy'.

Some of the other techniques are described in our publication-

Giant hiatus hernia: closure of the difficult hiatus - Falk, D'Netto, Little

Sept 2019 European Surgery

DOI: 10.1007/s10353-019-00612-4

In large hiatus herniae we have used mobilization of the oesophagus high in the chest (we agree fully with Dr Williamson) , and 'figure of 8' sutures to bring about secure apposition. Sutures placed obliquely bring about "recruitment of the left hemidiaphragm' -see video in the publication.

In relation to the use of 'pledget repair'

a comment and references in the publication -

"Disappointing experiences using Teflon pledget buttressed fundoplication highlighted the problems associated with foreign material around the hiatus [5,6]."

5. Baladas HG, Smith GS, Richardson MA, Dempsey MB,Falk GL. Esophagogastric fistula secondary to teflon pledget: a rare complication following laparoscopic fundoplication. Dis Esophagus. 2000;13(1):72–4.

6. Dally E, Falk GL. Teflon pledget reinforced fundoplication causes symptomatic gastric and esophageal lumenal penetration. AmJ Surg. 2004;187(2):226–9.

Hope this informs the discussion. Thank you for the interesting issues.

Cheers Trevor

If the fundus can be taken up and touch the Ant Abd wall in an isufflated abdomen comfortably,i agree with kamal that short gastrics need not be devided otherwise it is better to devide to prevent wrap disruption .

I never done it except once, however I work on few numbers per year so I learn from your experience and publications as well.

Thanks for the feedback. BW

That's a good plan Dr. Viswanath. I always practice hitching the wrap to the crura with 1-2 stitches. In some cases, I also take a stitch on the diaphragm as well.

Good to know. Cheers

Our experience and technique with laparoscopic images included in the publication-

Reference-

A Technique for the Laparoscopic Repair of Paraoesophageal

Hernia Without Mesh

Trevor J. D’Netto & Gregory L. Falk

J Gastrointest Surg

DOI 10.1007/s11605-013-2397-9

"Fundoplication and Gastropexy

The fixation and fundoplication were based upon the Menguy

procedure. The superior aspect of the posterior cardiopexy was passed around the oesophagus, ..... ...Two sutures incorporating generous ‘bites’ of the oesophagus and cardio-oesophageal junction, posterior fundus,

median arcuate ligament and repaired crus were placed using

2/0 Ethibond (Fig. 6). ...... Total fundoplication was then

completed by two sutures through the left-sided anterior fundus,

posterior fundus and right crus, ..........(Fig. 7). Further sutures were placed attaching the left fundus to the posterior left crus (Fig. 8). All sutures were tied

intracorporeally."

Best wishes.

We always anchor the posterior fundal wrap to the right crura and this has backing from evidence of

1. Majority of migration occur posteriorly and to the Left

2. During herniation, the anatomy of the hiatus is distorted to be almost oval with the left crus becoming more circular

3. The caudate lobe and the inherent more straght right crus prevents extra curvature of the right crura compard to the left; though both are anatomically derived from the right crura in a majority of patients

Therfore; anchorage prevents the fundus migration more so posteriorly and to the left