Innovative esophageal lengthening surgical technique in giant hiatal hernia repair

Giant hiatal hernia is defined as at least 30% of the stomach passing through the esophageal hiatus into the thoracic cavity. Surgical repair is the only treatment available for patients with symptomatic giant hiatal hernias. Robot-assisted laparoscopic giant hiatal hernia repair can result in excellent clinical outcomes. Here we present this surgical technique through a case of an elderly female who presented with symptomatic hiatal hernia. Esophagram confirmed the diagnosis of giant hiatal hernia. The patient underwent robot-assisted Type III hiatal hernia repair with Toupet fundoplication. During hiatal hernia repair, a short esophagus was encountered despite adequate mediastinal dissection. Instead of performing Collis gastroplasty, we resected 3 cm of fibrotic tissue from the esophagus. This led to the release of the esophagus and provided >2 cm of intra-abdominal esophagus. The patient subsequently underwent crus closure and Toupet fundoplication. The patient had resolution of symptoms after the operation. During giant hiatal hernia repair, when a short esophagus is encountered despite adequate dissection into the mediastinum, the novel technique of resection of the fibrotic tissue surrounding the esophagus above the stomach provides adequate length. This procedure avoids the need for Collis gastroplasty and provides symptomatic relief in patients with giant hiatal hernias.