Laparoscopic Hill Repair

Indications

Laparoscopic Hill Repair is indicated for:

• Gastroesophageal Reflux Disease (GERD):
  • Patients with symptomatic GERD who have failed or are intolerant to medical therapy (e.g., proton pump inhibitors – PPIs).
  • Patients who wish to avoid lifelong medication for GERD.
  • Persistent reflux symptoms such as heartburn, regurgitation, retrosternal pain, and coughing.
  • Complications of GERD, including reflux esophagitis and, in some cases, Barrett’s esophagus (though the primary goal is symptom control and reflux prevention).
• Hiatal Hernia: Especially sliding hiatal hernias associated with GERD. It can also be performed for paraesophageal hernias, often in conjunction with hernia sac excision and crural repair.
• Specific Patient Populations:
  • Patients with poor esophageal motility: The Hill repair is considered by some to be a good option in these patients as it aims to restore a physiological anti-reflux barrier without significantly increasing lower esophageal sphincter pressure in the same way a tight fundoplication might, potentially reducing the risk of postoperative dysphagia.
  • Post-bariatric surgery patients: It has been described as an alternative for managing GERD after procedures like sleeve gastrectomy or Roux-en-Y gastric bypass, as it doesn’t rely on having a full gastric fundus to create a wrap.
  • Patients with recurrent GERD after previous anti-reflux surgery.
  • Some surgeons may prefer it for young, healthy patients with symptomatic hiatal hernias who wish to avoid lifelong medication.
• Documented Reflux: Objective evidence of GERD through endoscopy, pH monitoring, and manometry is crucial. The Hill classification of the gastroesophageal valve (Grade I-IV) based on endoscopic appearance is often used in the assessment.

Preparation (Patient Preparation)

The preparation for a Laparoscopic Hill Repair is similar to other anti-reflux surgeries:

• Comprehensive Medical Evaluation:
  • Detailed history and physical examination.
  • Assessment of GERD symptoms, their severity, and impact on quality of life.
• Diagnostic Studies:
  • Upper Endoscopy (Gastroscopy): To visualize the esophagus, stomach, and duodenum; assess for esophagitis, hiatal hernia, Barrett’s esophagus; and rule out malignancy. The Hill grade of the gastroesophageal valve is often noted.
  • Esophageal Manometry: To evaluate esophageal peristalsis, lower esophageal sphincter (LES) pressure, and coordination. This helps in surgical planning and assessing suitability, especially if esophageal dysmotility is suspected.
  • 24-hour Ambulatory pH (or pH-Impedance) Monitoring: To quantify esophageal acid (and non-acid) exposure and correlate symptoms with reflux episodes. Patients are usually asked to stop reflux medications for a period before this test.
  • Barium Swallow/Esophagram: To delineate anatomy, identify the type and size of hiatal hernia, and assess esophageal emptying.
  • Bloodwork, Chest X-ray, EKG: As part of the general pre-operative work-up, depending on age and comorbidities.
• Lifestyle and Medication Adjustments:
  • Smoking Cessation: Strongly advised for several weeks before surgery.
  • Weight Management: If overweight, weight loss may be encouraged.
  • Dietary Modifications: Patients may be advised on dietary changes leading up to surgery. A normal meal the evening before, then fasting from midnight, is typical.
  • Medication Review: Discontinuation of blood thinners (aspirin, NSAIDs, anticoagulants) for a specified period. Continuation or adjustment of other medications as advised by the doctor.
• Preoperative Counseling: Detailed discussion about the procedure, its goals, potential risks, benefits, expected recovery, and long-term outcomes.
• Anesthesia Consultation: To assess fitness for general anesthesia.
• Bowel Preparation: Usually not required, beyond fasting.
• Logistics: Arranging for transportation home and post-operative support.

Patient Positioning

For a Laparoscopic Hill Repair, the patient is typically positioned as follows:

• Position: The patient is placed in a supine, split-leg (low lithotomy or modified Lloyd-Davies) position. This allows the surgeon to stand between the patient’s legs.
• Arm Placement: Arms may be out on arm boards or tucked at the sides.
• Table Tilt: The operating table is placed in a steep reverse Trendelenburg position (head up, feet down) to allow gravity to displace abdominal organs inferiorly, improving visualization of the esophageal hiatus.
• Strapping: The patient is securely strapped to the table.
• Surgical Team: The surgeon typically stands between the patient’s legs. The assistant is usually on the patient’s left, and the camera operator (or a robotic arm holder) on the right or as per surgeon’s preference.
• Monitors: Video monitors are placed for optimal viewing by the surgical team.

Port Placement

Laparoscopic Hill Repair is performed through several small abdominal incisions (ports). While slight variations exist, a common setup includes:

• Camera Port: Usually a 10-12 mm port placed supraumbilically or at the umbilicus for the laparoscope.
• Working Ports (typically 5 mm, though one may be 10-11 mm for the assistant or specific instruments):
  • Liver Retractor Port: A 5 mm port in the subxiphoid region for a Nathanson liver retractor to elevate the left lobe of the liver.
  • Surgeon’s Right-Hand Port: A 5 mm or 10 mm port in the left upper quadrant (e.g., mid-clavicular line below the costal margin). This port’s placement might be slightly more inferior than for a Nissen repair to facilitate suturing to the preaortic fascia.
  • Surgeon’s Left-Hand Port: A 5 mm port in the right upper quadrant.
  • Assistant Port: A 10-11 mm port may be placed just below the left costal margin in the mid-clavicular line or more medially. This port can be crucial for managing sutures during the gastropexy.
  • Optional Additional Port: A fifth or sixth port (e.g., in the left lower quadrant) might be used for retraction, particularly of lesser curvature fat, to improve exposure of the preaortic fascia.

The key is to achieve good triangulation and access to the esophageal hiatus and the preaortic area.

Intraoperative Steps

The Laparoscopic Hill Repair involves the following key steps, performed under general anesthesia:

1. Pneumoperitoneum and Port Insertion: The abdomen is insufflated with carbon dioxide, and trocars are placed.
2. Exposure and Mobilization:
   • The left lobe of the liver is retracted.
   • The gastrohepatic ligament (lesser omentum) is opened, carefully identifying and preserving any aberrant left hepatic artery.
   • The esophageal hiatus is dissected, mobilizing the distal esophagus circumferentially. Care is taken to identify and preserve the anterior and posterior vagus nerves.
   • The hernia sac, if present, is dissected from mediastinal structures and excised or reduced.
   • Sufficient intra-abdominal esophageal length (at least 3 cm) is achieved.
3. Crural Repair (Cruroplasty): The diaphragmatic crura are approximated posterior to the esophagus with non-absorbable sutures to narrow the hiatus. This repair should be snug but not constricting.
4. Identification of Preaortic Fascia and Median Arcuate Ligament: The area anterior to the aorta and inferior to the crural closure is dissected to clearly expose the preaortic fascia and the median arcuate ligament. This is the anchoring point for the gastropexy. The celiac trunk location is noted to avoid injury.
5. Calibration of the GEJ (optional but common): Intraoperative manometry or endoscopy may be used by some surgeons to assess the pressure and appearance of the GEJ as the repair is constructed, though not all find it necessary. An esophageal dilator (e.g., 48Fr) may be in place.
6. Placement of Hill Sutures (Gastropexy): This is the defining part of the Hill repair.
   • Several (typically 3 to 4, though some use fewer) non-absorbable sutures are placed.
   • Each suture takes bites through the anterior and posterior phrenoesophageal bundles (also referred to as the collar sling musculature) at the GEJ. The sutures incorporate the seromuscular layer of the stomach near the angle of His and along the lesser curvature aspect of the cardia.
   • These sutures are then passed through the dense preaortic fascia and median arcuate ligament.
   • When tied, these sutures pull the posterior aspect of the GEJ downwards and anchor it to the preaortic fascia, restoring the angle of His and reinforcing the anti-reflux barrier. The sutures effectively create a longer intra-abdominal esophageal segment and accentuate the flap valve mechanism.
   • Careful suture placement is critical to avoid injury to the aorta, vagus nerves, and to achieve the desired tension and anatomical restoration.
7. Final Inspection and Closure: The repair is inspected, hemostasis confirmed, instruments removed, CO2 desufflated, and port sites closed. A nasogastric tube, if used, may be removed.

Possible Complications and Management

While the Hill Repair is considered safe and effective, potential complications can occur:

General Surgical Risks:

• Bleeding
• Infection (wound or intra-abdominal)
• Injury to adjacent organs (esophagus, stomach, spleen, liver, aorta, vagus nerves)
• Thromboembolism (DVT, PE)
• Anesthesia-related complications
• Port-site hernia

Specific Complications of Hill Repair:

• Dysphagia (Difficulty Swallowing): While generally less common or severe than with Nissen fundoplication, it can occur, especially if the repair is too tight or due to postoperative edema. Most cases are transient and resolve with dietary modification. Persistent dysphagia may require investigation and potentially endoscopic dilation.
• Gas Bloat Syndrome: Less commonly reported than with 360-degree fundoplications, but symptoms like bloating and difficulty belching can occur.
• Recurrent Reflux/Heartburn: Although the Hill repair has shown good long-term durability, reflux can recur in some patients. This might be due to suture failure, loosening of the gastropexy, or development of a new hiatal defect. Management may involve lifestyle changes, medication, or, rarely, revisional surgery. Reoperation rates have been reported as low (under 10% in long-term follow-up for some series).
• Aortic or Celiac Axis Injury: A rare but serious risk due to the proximity of these structures during suturing to the preaortic fascia. Meticulous dissection and precise suture placement are crucial.
• Vagal Nerve Injury: Can lead to gastroparesis or diarrhea.
• Postoperative Pain: Usually manageable with standard analgesia.
• Migration or Failure of Sutures: Can lead to loss of the repair’s effectiveness.

Management of Complications:

• Conservative Management: For mild symptoms like transient dysphagia, dietary adjustments (liquid to soft diet progression) are often sufficient.
• Medical Therapy: PPIs or other acid-suppressing medications for recurrent reflux symptoms.
• Endoscopic Procedures: Esophageal dilation for persistent dysphagia. Endoscopy to assess the repair.
• Radiological Imaging: Barium swallow or CT scan can help evaluate the anatomy of the repair and identify issues like recurrent hernia.
• Revisional Surgery: May be necessary for significant complications like persistent severe dysphagia, intractable recurrent reflux due to repair failure, or suture-related problems. Revisional surgery is generally more complex.

The Laparoscopic Hill Repair is a specialized anti-reflux procedure with a distinct technique that focuses on anatomical restoration and fixation to the preaortic fascia. It offers excellent long-term durability and patient satisfaction, particularly when performed by experienced surgeons, and serves as a valuable alternative to fundoplication in appropriately selected patients.