Removal of the sac during surgery for the repair of “giant” paraesophageal hernias

Figure 1 Surgical approach results. A-D: Mobilization and complete evacuation of the hernia contents into the abdominal cavity (A: Type IV hiatal hernia; The esophageal hiatus is filled with great omentum and abdominal organs; B: Reduction of the transverse colon; C: Reduction of the stomach; D: Mobilization of the tissues inside the hernia sac in the mediastinum. The arrow shows the tissue of the left lung covered with the hernia sac); E-G: Mobilization of the neck of the hernia sac at the level of the diaphragmatic crura (E: A section of the neck of the hernia sac; F: Mobilization is performed, and the grasper fixes the edge of the hernia sac; G: The hernia sac is left in the mediastinum, and the neck of the sac is mobilized at the level of the diaphragmatic crura; H and I: Mobilization of the hernia sac); H: The hernia sac is mobilized and pulled down between the right crura and the esophagus; I: The hernia sac is mobilized and pulled down between the left crura and the esophagus; J-L: Reinforcement of the esophageal hiatus and fundoplication (J: Posterior crurorrhaphy was performed with nonabsorbable sutures; K: Polypropylene mesh was fixed around the esophagus; L: Nissen fundoplication was performed).