Procedural steps:

Preparation

1. Reverse Trendelenburg position

2. Attempt to insert NG tube for decompression, although this might not be possible under the stomach is reduced

Ports

Operative

1. Reduce the contents into the abdomen, the assistant will have to maintain the stomach in the abdomen once reduced (although the  cardia, gastrosplenic ligament and some short gastric often stay in the chest)

2. Dissect the sac anteriorly and left laterally until the anterior and left side of oesophagus is identified .. remember to preserve the left pleura and the anterior vagus nerve, gradually free the sac off the left crus completely and approach posteriorly

3. Retract the patient’s lesser omentum to the patient’s left and start by dissecting the hernia sac off the right crus (standard approach through window in pars flacida) and gradually clear the hernia sac off the right pleura, right oesophagus and the posterior vagus nerve. 

4. The sac can then be retracted laterally and upwards to dissect between the oesophagus and the aorta 

5. Division of short gastric is usually not needed 

6. Once the sac has been detached from the oesophagus and mediastinum, its either brought back into the abodmen or resected, depending on the size of the sac. A large lipoma is usually found around and must be removed to allow dissection of the lower oesophagus. the posterio vagus nerve has to be preserved with the oesophagus 

7. Its usually necessary to dissect the lower oesophagus from mediastinal attachements as well as the sac to allow 1-2 cm to sit in the abdomen.  (NB. if short oesophagus, the vagus nerves can be divided but along with pyloroplasty/pyloromyotomy)

8. To prevent intrathoracic migration, the hiatus is closed with sutures +/- pledgets +/- mesh. If mesh is needed, use PTFE as it produces fewer adhesions. Close the hiatal defect posterio to anterior using interrupted non-absorbable sutures (0-Ethibond). Normally 3-5 sutures are required. IN huge hiatal defects, 1 to 3 suture are also applied anterior to the oesophagus. (NB. if a bougie is considered, 50Fr)

9. To reinforce the repair, a 15x10cm vicryl (or even polypropylene) mesh with a slit along the middle leading to a 3cm hole can be fashioned and refixed around the oesophagus with staples or non-absorbable sutures. 

10. Funodplication is necessary as 30-40% have reflux and at least 20% will get reflux after the operation. You have to take care to perorm the wrap over teh oesophagus and not over the hernia sac

11. Gastropexy can be performed by fixing the fundoplication to the crura / the cardia or fundus to the diaphragm / fixing stomach to the anterior abbdominal wall (although this last one isnt show to reduce recurrence rate and can cause post-op complications). 

– eg. fix fundoplication to cura with 2 or 3 non-absorbable sturues, but only if crura is good quality (nb. fundoplication can be fixed onto the mesh as well)

12. Drain the mediastinal space if there is oozing