Concomitant Laparoscopic Hiatal Hernia Repair + TIF (c-TIF)
If patients have a hiatal hernia greater than 2 cm in size, or a gastroesophageal junction that is too loose (Hill Grade III or IV), we know that endoscopic therapy alone provides suboptimal results. In patients with anatomy disqualifying them from receiving TIF alone, we offer a combination laparoscopic and endoscopic approach to achieve GERD relief – c-TIF. The goal of this approach is to provide the least invasive intervention possible to achieve durable symptom relief while avoiding the long-term side effects of traditional anti-reflux surgery.
A hiatal hernia develops when the diaphragm – the breathing muscle that separates the abdominal and chest cavities – has become too lax around the bottom of the esophagus. Normally, the esophagus enters into the abdomen through an opening called the diaphragmatic hiatus. Membranes attached between the diaphragm and the esophagus help keep the esophagus and the stomach below it fixed in place. The diaphragm itself also keeps pressure around the esophagus, which helps to buttress the lower esophageal sphincter – the muscle valve that normally prevents stomach acid from washing back up to the stomach.
Over time (and with increased pressure in the abdomen due to obesity), the membranes fixing the esophagus in place can break down and the diaphragm hiatus can start to loosen resulting in a hiatal hernia where the stomach has moved up into the chest cavity. A hiatal hernia can cause or exacerbate acid reflux for a number of reasons. The hernia results in distortion of the normal structure meant to prevent reflux. Fluid also now pools within the herniated top of the stomach and can easily wash back into the esophagus. In addition the lower esophageal sphincter is now no longer in the abdominal cavity, but in the chest cavity, where it is exposed to the negative pressure produced in order to suck air into the lungs. This negative pressure also sucks open the sphincter, promoting reflux.
While the endoscopic TIF procedure can reduce a hiatal hernia up to 2 cm in size, larger hernias require hernia repair. Additionally, If the diaphragm is too loose around the esophagus, even if TIF temporarily reduces a hernia, it may recur unless the diaphragmatic defect is repaired. Diaphragmatic repair requires surgical intervention.
How it works
During c-TIF, the surgeon first laparoscopically reduces the hiatal hernia by pulling the stomach and the bottom of the esophagus back into the abdominal cavity. The diaphragmatic defect is then repaired with the use of sutures that re-tighten the diaphragm around the distal esophagus, narrowing the opening of the hiatus. During the same procedure, endoscopic TIF is then performed to re-create and strengthen a valve structure that serves as a barrier to acid reflux.